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VASORENAL    CHANGE; 


SIXTY   YEARS'   FURTHER   STUDY   OF   THE 
PATHOLOGICAL    PROCESS 

FIRST    OBSERVED    BY 

DR.    RICHARD     BRIGHT,    F.R.S. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/vasorenalchangevOOfoth 


VASORENAL    CHANGE 


i'EHSUS 


BRIGHT'S    DISEASE. 


BY 

J.  MILNER  FOTHERGILL,  M.D.  Edin., 

physician  to  the  city  of  london  hospital  for  diseases  of  the  chest 

(victoria  park)  ; 

late  assistant-physician  to  the  west  london  hospital  ; 

hon.  m.d.,  rush,  ill.  ; 

foreign  associate  fellow  of  the  college  of  physicians,  philadelphia. 


'  Je  vieillis 


New  York  :    G.  P.  PUTNAM'S  SONS, 
27  and  29,  West  23D  St. 

London  :    BAILLIERE,    TINDALL,    AND    COX. 
1887. 


'  Old  age  is  not  an  entity,  but  a  set  of  conditions  predisposing  to  that  state 
which  is  called  Chronic  Bright's  Disease.  And  while  to  most  this  comes  in 
natural  order  when  the  prime  of  life  is  run,  yet  to  some  old  age  is  no  matter 
of  years  and  averages,  but  the  running  down  of  a  spring  set  for  an  individual.' 

GOODHART. 


^o   the   JVtcmory 

OF 

RICHARD    BRIGHT,    M.D.,    F.R.S., 

THE    FIRST   OBSERVER   OF   THIS   CHANGE, 

THIS    WORK 

is 

HUsjmtfxiUg    ^cbicatci 

BY 

THE   AUTHOR. 


PREFACE. 


This  work  is  written  under  a  deep  sense  of  responsibility. 
Of  the  necessity  for  some  other  term  than  '  Bright's 
Disease'  in  the  present  state  of  our  knowledge,  no  ques- 
tion can  exist.  It  is  now  fifteen  years  since  the  writer 
attempted  to  grapple  with  this  widespread  morbid  change, 
in  the  chapter  '  Combined  Heart  and  Kidney  Disease,'  in 
the  first  edition  of  his  work,  The  Heart  and  its  Diseases. 
This  may  form  some  explanation  for  his  venturing  upon 
the  present  essay.  Before  taking  action,  however,  he 
obtained  the  sanction  of  the  leading  professors  and 
lecturers  on  the  Practice  of  Mtdicine  to  the  attempt 
being  made  ;  and  he  has  done  his  best. 

His  best  thanks  are  due  to  Dr.  Mott,  his  draughtsman, 
and  Mr.  Hanlon,  his  engraver,  for  the  excellent  wood- 
cuts which  illustrate  the  text.  Also  to  Dr.  D.  G.  L. 
Johnston  and  Henry  T.  Wharton,  M.x\.,  for  their  aid  in 
revising  the  proof  sheets. 

3,  Henrietta  Street,  Cavendish  Square, 
June  i,  1887. 


LIST  OF  ILLUSTRATIONS. 


FIG.  1'AGE 

i.  Rabbit's  Eye  (Fcetal)         ...  -      30 

2.  Section  of  Kidney  Cortex  (Granular)  -      34 

3.  Section  of  Thickened  Artery  -           -  -           -44 

4.  Sphygmographic  Tracing  --.'.-  45 

5.  Deposits  of  Urate  of  Soda        -           -  50 

6.  Teeth  (Gouty)         -           -                       -  85 

7.  Nails  (Gouty)                     -  87 

8.  Sections  of  Two  Small  Arteries          -  - ";-           -      96 

9.  Miliary  Aneurysms            -  -     100 

10.  Section  of  Normal  Kidney         -           -  -     103 

11.  Schema  of  Kidney-           -  104 

12.  Glomerulus  of  Kidney  (Healthy)  -            -     105 

13.  Early  Change  in  Glomerulus    -  -           -     in 

14.  Section  of  Granular  Cortex     -           -  -           -     112 

15.  „                    „                   ,,        more  Advanced  -     113 

16.  Tube  Casts-            -           ■•           -           -  -           -    11S 

17.  Sections  of  Arteries        -           -  -                157 

18.  Heart  Fibres  (Fatty)        -  15S 

19.  Section  of  Congested  Granular  Kidney  -           -     171 


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Historical 


CONTENTS 


CHAPTER  I. 


CHAPTER  II. 
Primal  Departures. 


a.  Uric  Acid  Formation  (Reversion) ;  b.  Vaso-Motor  Disturbance  ; 
c.  Growth  of  Connective  Tissue         -  9-3^ 


CHAPTER  III. 
First  Stage. 

The  NORSE  Type  {Changes  in  the  Tissues  of  the  Mesoblast)  : 
Changes  in  the  Vascular  System — Joint-Gout — Rheumatism — 
Chronic  Bronchitis — Emphysema — Eczema — Secondary  Val- 
vular Disease  in  the  Heart     -  -  -  37-57 

The  Neurotic,  or  Arab  Type  (Changes  in  the  Tissues  of  the 
Hypoblast  and  Epiblasf)  :  Digestive  Troubles — Biliousness — 
Skin  Affections  ■•—  Migraine  —  Mental  Phenomena  —  Cardiac 
Neuroses        -------       58-82 

Some  Practical  Points  ------       82-8S 


xi  i  CONTENTS. 

CHAPTER    IV. 
Middle  Stage. 

PAGE 

a.  Diseases  of  the  Vascular  System  :  Palpitation — Angina  Pectoris 
Vaso-motoria — Epistaxis— Atheroma — Aneurysm — Apoplexy — 
Gangrene        -------     89-102 

b.  Changes  in  the  Kidney  :  Interstitial  Nephritis — Tube-casts — 
The  Urine — Albuminuria — Glycosuria  -  102-133 

c.  Results  of  Toxic  Blood :  Uraemia — Secondary  Inflammations 
— Gouty  Asthma— Albuminuric  Retinitis — Dupuytren's  Con- 
traction -------  133-139 

Some  Practical  Points   -  -   139-140 

CHAPTER  V. 

Advanced  Stage. 

General  Considerations  —  Lead  —  Occlusion  of  the  Coronary 
Vessels  with  Fatty  Degeneration  of  the  Heart — Arcus  Senilis  — 
The  Descent — Venous  Fulness — Interstitial  Changes — Dropsy 
— Albuminuria — Serous  Effusions  — Death,  Sudden  or  Slow   141-175 


CHAPTER  VI. 

Practical  Considerations. 

a.  Insurance  Office  View  of  Life  ;  b.  Surgical  Aspect  of  Vaso- 
Renal  Change  ;  c.  Relations  of  Stomach  and  Liver  ;  d.  Treat- 
ment—Dietary -  -  1 76-20; 


L'ENVOI  -  .  -  -  204-216 

INDEX  -  -  217-219 


$$  ftgtf 


FROM  THE  ORIGINAL  OF  D?  BRIGHj 


FROM  THE  ORIGi::- 


YASO-RENAL     CHANGE 

VERSUS 

'BRIGHT'S    DISEASE.' 

CHAPTER     I. 

HISTORICAL. 

'  So  long  as  a  disease  carries  a  man's  name  it  shows  we 
know  little  about  it,'  was  the  remark  of  Sir  James  Paget  to 
the  writer  of  this  monograph,  when  discussing  its  subject- 
matter  with  him,  preparatory  to  writing  it. 

That  many-linked  chain  of  morbid  sequences  which 
for  some  time  past  has  been  known  as  '  Chronic  Bright's 
Disease,'  only  came  within  the  sphere  of  our  vision  in 
the  present  century.  In  1813  Dr.  Blackall,  of  Exeter, 
published  a  treatise  on  '  Dropsy,'  in  which  he  has  a  great 
deal  to  say  about  '  coagulable  urine.'  But  in  a  great 
many  cases  the  kidneys  were  not  examined  after  death. 
In  other  cases  they  were  examined  and  pronounced 
'  sound,'  where  it  is  morally  certain  from  the  histories  of 
the  cases  that  some  interstitial  nephritis  must  have  been 
present,  but  passed  unrecognised.  In  other  cases  the 
renal  organs  were  observed  to  be  diseased,  as  the  follow- 
ing passage  shows  :   '  The   kidneys,  likewise,  have  been 

1 


2  VA SO-RENAL  CHANGE. 

diseased  in  an  unusual  proportion  in  such  dissections. 
In  no  less  than  three  instances  out  of  the  eleven  here  re- 
ferred to — viz.,  three  in  Dr.  Wells's  work,  and  eight  in 
mine — they  were  thickened  or  hardened,  and  even  with  a 
confused  structure,  etc.,  two  or  three  containing  hydatids, 
or  vesicles.'* 

In  1817,  Mr.  James,  of  the  same  city,  pointed  out  how 
a  hindrance  to  the  blood-flow  in  the  smaller  arteries 
caused  a  fulness  in  the  larger  arteries,  which  in  its  turn 
led  to  hypertrophy  of  the  left  ventricle.  But  these  com- 
bined observations  seem  to  have  slipped  out  of  the  medical 
mind  of  that  time.  And  it  was  not  until  the  appearance 
of  Dr.  Richard  Bright's  magnificent  '  Medical  Reports  ' 
that  the  medical  profession  realized  that  changes  in  the 
kidney  could  be  a  cause  of  death.  Dr.  Bright  was  a 
great  pathologist,  whose  attention  was  not  devoted  to 
the  kidneys  solely,  and  when  his  '  Reports '  appeared 
(1827-32),  we  cannot  be  surprised  at  the  effect  they 
produced  on  the  medical  profession  throughout  the 
civilized  world.  The  association  of  dropsy  and  albu- 
minuria with  disease  of  the  kidney  was  kosmos  out  of 
chaos.  He  first  saw  their  relations  as  cause  and  effect, 
while  Dr.  Blackall  and  others  merely  noted  what  seemed 
to  them  as  coincidents.  His  views  were  based  upon 
careful  observations,  and  his  beautiful  coloured  plates 
(two  of  which  are  reproduced  in  this  work)  attracted  as 
much  attention  from  their  pathological  as  from  their 
artistic  merits. 

'■'  How  near  Dr.  Blackall  was  to  a  complete  grasp  of  the  vaso-renal 
change  will  be  shown  later  on.  Had  he  but  had  the  aid  of  the 
microscope  to  reveal  to  him  the  condition  of  the  small  arteries,  he 
might  have  anticipated  our  present  knowledge. 


HISTORICAL.  3 

Sir  Robert  Christison,  in  his  article  '  Granular  Disease 
of  the  Kidney,'  in  the  '  Library  of  Medicine,'  took  much 
the  same  view,  and  saw  several  maladies  '  to  be  occa- 
sioned by  poisoning  of  the  blood  with  the  undischarged 
principles  of  the  urine.'  But  he,  too,  saw  'as  through  a 
glass  darkly,'  other  associations  of  this  change  in  the 
kidney,  for  he  wrote  :  '  Lastly,  organic  disease  of  the  liver 
and  heart  concur  very  frequently  with  granular  degenera- 
tion of  the  kidneys.  Sometimes  the  one,  sometimes  the 
other  disease  is  obviously  first  in  origin  ;  at  other  times  it 
is  impossible  to  say  which  commenced  first ;  and  occa- 
sionally the  three  organs  are  affected  together,  and  nearly 
to  the  same  degree.  The  most  common  affection  of  the 
heart  is  hypertrophy  with  or  without  valvular  obstruction.' 

The  microscopic  appearances  of  such  kidneys  were 
studied  by  C.  J.  B.  Williams,  Dr.  Geo.  Johnson,  and  Dr. 
Richard  Quain.  The  latter  wrote  an  article  on  '  The 
Pathology  of  Bright's  Disease  of  the  Kidney,'  in  the 
Lancet  of  November,  1845,  dividing  the  renal  changes 
into :  J,  simple  enlarged  mottled  kidney  ;  2,  truly  gran- 
ular or  atrophied  kidney  ;  and  3,  the  large  flabby,  fatty- 
looking  kidney.'  Of  the  second  form,  the  granular 
kidney,  he  writes  :  '  The  truly  granular  or  atrophied  kidney, 
the  surface  of  which  is  rough,  irregular,  and  generally  of 
a  pale  reddish  colour.  In  this  form,  the  filamentous  tissue, 
contractile  in  its  nature,  as  such  formations  always  are, 
exceeds  the  quantity  of  the  cellular  or  granular  matter. 
The  latter  I  have  observed  extending  to  the  convoluted 
extremities  of  the  tubes.  The  contractile  tissue  surround- 
ing the  tubes  and  bodies  can  be  readily  supposed  to  give 
rise  to  the  rough  or  granular  formation.  The  form 
resembles  the  hob-nailed  or  gin-liver.' 

1 — 2 


4  VASO-RENAL  CHANGE 

There  seems  at  this  period  of  time  to  have  been  some 
differences  of  opinion  as  to  the  nature  of  the  changes 
known  as  '  Bright's  Disease.'  For  in  1849  Professor 
Walshe  delivered  a  clinical  lecture  at  University  College 
on  '  Bright's  Disease  not  essentially  a  Renal  Disease,  but 
essentially  and  primarily  a  Blood  Disease,'  in  which  he 
made  the  following  statement  :  '  I  have  long  believed  for 
my  own  part  that  the  views  which  localise  that  affection 
in  the  substance  of  the  kidney,  and  regard  the  anatomical 
changes  in  that  organ  as  the  essence  of  the  malady,  are 
one-sided  and  contracted.  I  recognise  in  the  natural 
history  of  the  disease  tolerably  sure  evidence  of  primary 
origin  in  the  blood.' 

As  to  the  stream  of  investigation  into  changes  in  the 
kidney,  gross  and  microscopic,  it  is  unnecessary  to  follow 
it  here.  What  is  rather  my  wish  here  is  to  keep  the 
changes  in  the  circulating  organs  well  in  view,  which 
have  been  too  little  regarded  by  many.  Rokitanski 
observed  that  apoplexy  proving  quickly  fatal  (foudroy- 
ante)  with  a  large  blood-clot  occurred  in  persons  with 
large  hearts. 

Latham,  in  his  famous  treatise  on  the  heart,  1845,  in 
speaking  of  disease  of  the  arteries,  points  to  its  connec- 
tion '  with  hypertrophy  and  dilatation  of  the  left  ventricle.' 
Continuing  :  '  We  see  that  the  disease  of  the  arteries  has 
reached  a  more  onward  stage,  and  made  larger  and  more 
extensive  deposits  of  cartilage  and  atheroma  and  bone, 
while  the  liver  and  spleen  and  the  kidney  are  found 
enlarged  and  granulated ;  and  the  transparent  mem- 
branes, as  the  pleura  and  peritoneum,  are  thickened  and 
opaque.  And  it  is  strange  if  they  have  not  a  connection 
with  the  disease  diffused  throughout  the  arteries  ;  and  it 


HISTORICAL.  5 

is  strange,  moreover,  if  they  have  not  all  a  connection 
with  the  hypertrophy  and  dilatation  of  the  heart.'  Dr. 
Latham  was  a  wise  and  far-sighted  physician,  in  many 
matters  much  in  advance  of  his  times. 

In  1855  Professor  Traube,  of  Berlin,  published  some 
observations  on  the  connection  (Zusammenhang)  of 
chronic  heart  enlargement  with  disease  in  the  kidneys. 
From  this  time  a  connection  betwixt  disease  of  the 
kidneys,  of  the  nature  of  interstitial  nephritis,  and  changes 
in  the  vascular  system,  and  especially  enlargement  of  the 
left  ventricle,  has  been  generally  recognised.  Traube 
held  that  the  obstruction  to  the  circulation  in  the  kidneys 
augmented  the  work  of  the  heart,  and  so  led  to  hyper- 
trophy. (A  view  which,  to  my  personal  knowledge,  he 
greatly  modified — though  he  did  not  publish  these  later 
views.)  While  Bamberger  held  that  the  enlargement  of 
the  heart  occurred  before  there  was  any  distinct  obstruc- 
tion to  the  circulation  through  the  kidney. 

Then  new  light  came  in  from  another  side.  Traube 
found  that  retained  urine-salts  in  the  blood  caused 
arteriole  spasm  as  evidenced  by  an  increase  in  arterial 
tension ;  a  view  taken  up  by  Ludwig.  Urine  injected 
into  the  blood,  it  was  found,  produced  the  same  effect. 
The  commencing  point  of  the  widespread  change  was 
now  being  tracked  down  to  a  change  in  the  blood.  Thus 
the  idea  that  Bright's  Disease  was  primarily  a  blood 
change  (as  stated  by  Walshe)  was  now  made  clearly 
apparent. 

Then  the  microscope  came  on  the  scene.  In  1862 
Dr.  Handheld  Jones  described  '  Fibrosis  of  the  Arteries  ' ; 
and  in  1870  a  notable  discussion  took  place  at  the 
Medico-Chirurgical    Society  betwixt   Sir  Wm.    Gull  and 


6  VASO-RENAL  CHANGE. 

Dr.  Sutton  on  the  one  part,  and  Dr.  Johnson,  of  King's 
College,  on  the  other  part.  Dr.  Johnson  had  been 
demonstrating  a  thickening  of  the  muscular  wall  of  the 
arterioles  in  cases  of  Bright's  disease  with  an  enlarged 
left  ventricle.  Sir  Wm.  Gull  and  Dr.  Sutton  exhibited 
sections  of  arterioles  which  had  undergone  another  form 
of  change  which  they  termed  '  arterio-capillary  fibrosis.' 
A  brief  warfare  raged  over  the  matter,  and  the  contro- 
versy attracted  general  attention  to  the  subject.  Sides 
were  taken  by  men  who  knew  very  little  about  the 
matter ;  while  a  few  investigated  the  subject.  Among 
these  were  Drs.  Quain,  Garrod  and  Broadbent,  in  Eng- 
land ;  Professors  Rutherford  and  Grainger  Stewart,  in 
Scotland ;  and  Dr.  Ringrose  Atkins  in  Ireland. 

Clinical  observations  grew  more  acute  in  the  mean- 
time :  and  Dr.  Dickenson  wrote  :  '  Since  I  have  had  my 
attention  particularly  directed  to  this  subject,  I  have 
scarcely  seen  an  instance  in  which,  if  the  renal  state  was 
distinctly  recognised,  whether  after  death  or  in  life,  some 
degree  of  cardiac  hypertrophy  was  not  also  apparent.  I 
have,  in  fact,  got  to  regard  simple  cardiac  hypertrophy  as 
one  of  the  most  important  diagnostic  signs  of  renal  fibrosis.' 
That  the  increased  arterial  tension  of  this  state  produced 
an  accentuated  aortic  second  sound,  was  pointed  out  by 
Rosenstein.  The  increased  bulk  of  urine  of  this  condi- 
tion Traube  showed  was  due  to  this  heightened  arterial 
tension. 

In  1S72,  in  the  first  edition  of  my  work,  '  The  Heart 
and  its  Diseases,'  is  to  be  found  a  chapter  devoted  to  the 
consideration  of  '  Combined  Heart  and  Kidney  Disease,' 
and  descriptive  of  the  condition  to  which  the  term  '  The 
Gout}-  Heart  '  was  applied  in  the  second  edition  (1879). 


HISTORICAL.  7 

Fifteen  years  of  further  attention  to  the  subject  may  be 
a  sufficient  vindication  for  the  writing  of  the  present 
essay. 

In  the  meantime  the  study  of  the  sphygmograph  was 
yielding  good  fruit.  The  late  Dr.  Mahomed  rendered 
himself  specially  conspicuous  amongst  a  band  of  workers, 
including  Sir  Walter  B.  Foster,  M.D.,  Professor  Burdon 
Sanderson,  Drs.  W.  H.  Broadbent,  Galabin,  Goodhart, 
and  others.  Dr.  Mahomed  was  attached  to  the  London 
Fever  Hospital,  and  made  a  study  of  cases  of  scarlatinal 
nephritis.  From  this  he  proceeded  to  read  a  paper 
before  the  Medico-Chirurgical  Society  (1874)  on  '  The 
Etiology  of  Bright's  Disease,  and  the  pre-Albuminuric 
Stage,'  which  attracted  much  attention.  Dr.  Goodhart 
said  in  his  Bradshawe  lecture  (1885)  on  '  Morbid  Arterial 
Tension '  (which  lecture  as  originally  intended  should 
have  been  delivered  by  Dr.  Mahomed  himself,  but  his 
untimely  death  prevented  it)  '  it  bears  directly  upon  the 
present  part  of  our  subject.  In  it  was  shown  precisely 
that  morbid  condition  of  the  pulse  (high  tension)  precedes 
any  evidence  of  disease  in  the  kidney  ;  and  he  draws  the 
conclusion  from  a  number  of  observations,  that  the 
vascular  condition  is  the  cause  of  the  albuminuria,  and  not 
the  converse,  as  has  been  generally  supposed.' 

The  present  position  of  our  knowledge  on  this  subject 
is  about  this  : — 

A  waste-laden  condition  of  blood  causes  contraction  of 
the  tiny  arterioles,  producing  high  arterial  tension.  This, 
in  turn,  leads  to  enlargement  of  the  left  ventricle.  The 
sustained  high  arterial  tension  sets  up  atheromatous 
change  in  the  arterial  wall ;  and  from  this  spring  a  number 
of  maladies.    Spasm   of  the  arterioles  gives  angina  pectoris 


8  V A  SO-RENAL  CHANGE. 

vaso  motoria.  The  enlarged  heart  is  liable  to  secondary 
valvular  change — the  result  of  strain  upon  the  valves. 
While  the  blood  laden  with  waste,  or  excrementitious 
matter,  possesses  distinct  toxic  properties,  giving  us  gout 
in  all  its  protean  forms ;  secondary  inflammations  of 
serous  membranes,  bronchitis,  and  skin  affections.  Lithse- 
mia  and  uraemia  are  part  of  the  troubles  occasioned  by 
the  blood-change.  The  growth  of  connective  tissue  at 
the  expense  of  the  other  structures  of  the  kidneys  in  time 
works  their  ruin,  giving  us  intestinal  nephritis,  and 
with  it  what  Sir  Andrew  Clark  terms  '  renal  inadequacy.' 
While  albuminuria  and  glycosuria  are  not  uncommonly 
found.     Ultimately  there  is  heart-failure,  and  death. 

Some  more  detailed  account  of  these  morbid  stages  will 
be  given  later  on  ;  but  from  what  has  been  already  stated 
it  is  abundantly  clear  that  the  term  '  Chronic  Bright's 
Disease  '  is  no  longer  adequate,  but  is  '  one-sided  and  con- 
tracted ;'  and  therefore  that  some  new  term  is  necessitated 
by  the  further  extension  of  our  knowledge ;  without  any 
intention  to  disparage  the  work  of  the  excellent  patholo- 
gist and  clinical  observer  who  first  noted  this  morbid 
change. 


CHAPTER  II. 

PRIMAL    DEPARTURES. 

a.  Uric  Acid  Formation   (Reversion)  ;  b.  Vaso-Motor  Disturbance  ; 
c.  Growth  of  Connective  Tissue. 

The  view  that  the  origin  of  '  Bright's  Disease '  was  con- 
nected with  the  blood  has  steadily  gained  ground,  until  it 
now  holds  the  field  unquestioned.  Further,  it  is  hardly 
in  dispute  that  the  materies  morbi  is  uric-acid.* 

The  Uric-Acid  Formation. — This  has  been  hitherto 
termed  '  gout,'  because  the  first  recognition  of  it  began 
with  those  changes  which  appealed  to  the  eye.  Drop  by 
drop  (goutte),  something  from  the  blood  was  deposited 
in  the  articular  cartilages  of  the  small  joints,  producing 
obvious  deformity.  The  great  toe  was  the  favourite 
locality  for  this  materies  morbi,  while  the  knuckles  were 
also  commonly  affected.  Occasionally  deposits  were  found 
in  larger  joints.  A  like  deposit  was  recognised  on  the 
pinnae  of  the  ears  (otolites).  Points  exposed  were  appa- 
rently selected.  These  exposed  points  appealed  to  the 
eye,  which  made  the  diagnosis  of  gout,  or  gravel. 

It  was  not  until  chemistry  had  cleared  up  the  composi- 

*  What  part,  if  any,  is  played  by  the  earlier  members  of  the 
descending  series  of  albumen-metamorphosis  ending  in  uric  acid  and 
urea,  is  unknown. 


io  V A  SO-RENAL  CHANGE. 

tion  of  this  materies  morbi  that  the  essence  of  the  malady 
was  recognised.  When  it  was  ascertained  that  the  de- 
posited matter  was  urate  of  soda,  the  next  step  was  to 
find  out  if  this  substance  existed  in  the  blood  of  these 
'  gouty  '  persons.  This  matter  was  demonstrated  by  Dr. 
Garrod.  With  this  discovery  came  new  light.  The 
old  idea,  that  '  chalk-stones  '  (as  these  formations  of  urate 
of  soda  were  termed)  were  deposited  drop  by  drop  from 
the  blood,  was  seen  to  be  correct.  They  were  the  outward 
and  visible  signs  of  a  hidden  condition  of  the  blood.  Now 
it  became  possible  to  understand  the  relation  of  certain 
subjective  matters  to  visible  gouty  formations.  There 
were  bodily  sensations  and  mental  phenomena,  as  Syden- 
ham knew,  linked  with  the  uric  acid  formation,  and  re- 
lieved by  an  outbreak  of  articular  gout.  The  connection, 
as  a  clinical  fact,  was  distinctly  recognised.  Other  por- 
tions of  the  body  were  affected  injuriously  by  the  uric  acid 
circulating  in  the  blood.  Gout  was  now  recognised  as  a 
blood  condition  ;  still  the  old  term  lived  on  tenaciously, 
being  prefixed  by  the  adjectives  'latent,'  or  'suppressed,' 
or  '  irregular,'  or  '  retrocedent.'  Advancing  knowledge 
entailed,  as  it  ever  must,  a  changing  phraseology ;  and 
with  that  some  inevitable  confusion. 

At  this  point  it  may  be  well  to  ask  the  pertinent  ques- 
tion, Why  are  exposed  joints  liable  to  be  the  seat  of 
deposits  of  urates  ?  Why  do  the  urates  in  the  urine  fall 
as  a  sediment  to  the  bottom  of  the  chamber  utensil  during 
a  frosty  night  ?  They  are  not  obvious  when  the  urine  is 
voided ;  they  do  not  become  visible  till  a  certain  tem- 
perature is  reached.  If  the  urine  be  warmed  they  dis- 
appear. The  liability  of  the  hands  and  feet,  and  the 
pinnte  of  the  ear  to  be  chilled  is  certainly,  a  part  at  least 


PRIMAL  DEPARTURES.  n 

of  the  cause  of  the  deposit  of  urates  in  them.  But  there 
must  be  something  more  than  mere  liability  to  a  low 
temperature,  for  we  do  not  find  chalk-stones  in  the  nose, 
which  is  equally  exposed  to  the  action  of  a  low  tempera- 
ture, on  the  one  hand;  and  we  do  find  the  aortic  valves  to 
be  liable  to  gouty  changes,  and  they  surely  are  never 
chilled.  There  must  be  something  in  the  nature  of  the 
cartilage  to  invite  deposits  of  uric  acid.  But  so  far  my 
inquiries  of  various  histologists  has  failed  to  elicit  any 
explanation. 

Then  again,  stone  and  gravel  were  matters  which  ap- 
pealed to  the  eye,  and  were  at  an  early  period  recognised 
as  associates  of  articular  gout.  They  show  conclusively 
that  uric  acid  can  crystallise  at  the  temperature  of  the  body. 

From  these  considerations  we  can  understand  how  the 
uric  acid  formation  first  revealed  itself  in  obvious  discern- 
ible morbid  changes  ;  and  how  it  came  about  that  these 
were  slowly  recognised  to  go  hand  in  hand  with  certain 
inward  changes  and  subjective  sensations,  as  matters  of 
clinical  fact. 

What  is  this  uric  acid  formation  ?  For  long  the 
connection  of  gout  with  high  feeding,  and  the  well-known 
fact  that  it  lay  hid  in  the  shadow  of  wealth,  obstructed  a 
right  and  true  conception  of  its  real  nature.  It  was  held 
as  something  added  to  a  healthy  person,  as  a  consequence 
of  indulgence  of  the  palate.  The  fact  of  gout  occurring 
with  abstinence  was  recognised  as  conflicting  with  this 
view ;  and  as  a  partial  solution  of  this  anomaly  the 
phrase  '  poor  man's  gout  '  came  into  fashion.  So  long  as 
the  theory  of  gout  being  something  added  to  a  person  by 
high  feeding  held  sway,  so  long  was  it  simply  impossible 
to  comprehend  why  the  uric  acid  formation  came  to  be 


12  V A  SO-RENAL  CHANGE. 

found  in  persons  of  notable  abstinence  and  small  eaters. 
The  fact  that  the  children  of  gouty  parents  were  liable  to 
inherit  gout  was  a  small  contribution  towards  a  solution. 
'  The  fathers  have  eaten  sour  grapes  and  the  children's 
teeth  are  set  on  edge.'  If  the  offspring  of  gouty  parents 
practised  great  abstinence  as  to  eating  and  drinking,  they 
more  or  less  completely  escaped  the  clutches  of  their 
hereditary  foe.  Those  who  indulged  suffered  for  it. 
Those  who  practised  abstinence  escaped.  That  persons 
of  gouty  descent  can  keep  the  gout  at  bay  by  poor  living 
is  as  true,  as  that  a  man  may  acquire  gout  for  his 
descendants.  Take  the  case  of  the  poor  gentleman  of 
straitened  means  who  is  never  attacked  by  the  gout, 
except  when  he  goes  on  a  visit  to  a  wealthy  relation, 
when  a  few  days  of  good  living  evoke  acute  articular 
gout  ;  and  contrast  it  with  the  case  of  the  plebeian-born, 
self-made  man,  who  eats  and  drinks  at  will,  and  himself 
knows  nothing  of  the  gout.  How  comes  this  about  ? 
The  one  has  an  inheritance  of  good  living,  of  ancestral 
livers  well-employed  for  generations.  The  other  is  born 
of  poverty  and  scanty  fare.  The  one  has  what  Dr. 
Budd  called  an  'insufficient  liver;'  the  other  has  a  liver 
in  all  its  integrity.  With  the  former  a  trifling  indul- 
gence brings  out  the  inheritance  of  a  tendency  to  uric  acid 
formation  ;  while  the  liver  of  the  latter  remains  capable  of 
meeting  all  the  demands  made  upon  it.  The  plebeian- 
born  man  acquires  the  gout  with  his  fortune — and  leaves 
them  both  to  his  descendants. 

The  uric  acid  formation  then  is  closely  linked  with  an 
incompetent  liver.  That  is  another  contribution  to  our 
acquaintance  with  this  complex  subject. 

If  a  person  possesses  a  functionally  feeble  or  insufficient 


PRIMAL  DEPARTURES.  13 

liver,  that  fact  renders  him  or  her  liable  to  the  uric  acid 
formation  without  any  indulgence  of  the  palate.  Many 
persons  who  eat  but  little  possess  a  great  tendency  to 
gout  in  some  form  in  consequence  of  their  liver  disability. 
Now  the  'poor  man's  gout'  stands  unveiled  before  us, 
i.e.,  the  uric  acid  diathesis.  Gout  poison  has  its  associa- 
tions with  '  blue  blood ;'  and  the  person  liable  to  '  poor 
man's  gout '  is  often  the  inheritor  of  a  naturally  incapable 
liver  as  the  result  of  gastronomic  indulgence  on  the  part 
of  his  ancestors.* 

The  matter  of  liver  insufficiency  will  engage  our  atten- 
tion at  greater  length  when  dealing  with  vaso-renal  change 
in  the  '  Neurotic  ;'  when  we  shall  see  small  spare  beings 
who  eat  but  little,  and  who  often  instinctively  loathe 
animal  food  ;  yet  they  are  liable  to  the  uric  acid  forma- 
tion. What,  then,  is  this  uric  acid  formation  which  has 
two  associations  :  (1)  '  The  rich  man's  gout,'  where  the 
liver  is  chronically  overburdened  by  food  excesses;  and  (2) 
'  The  poor  man's  gout '  where  an  insufficient  liver  has  no 
great  burden  to  bear  ?  It  is  reversion,  or  a  falling  back 
on  the  part  of  the  liver. 

Dr.  Lauder  Brunton  writes  me :  '  Another  point  of 
interest  in  regard  to  reversion  is  the  tendency  of  children 
to  form  uric  acid  before,  or  within  a  few  days  after  birth. 
This  tendency  appears  to  indicate  a  primitive  uric  acid 
formation ;  because  the  early  life  of  the  embryo  appears 
to  correspond  with  the  life  history  of  the  race.'  This  is 
linked  doubtless  with  the  fcetal  circulation  being  that  of 
the  higher  reptiles. t 

0  We  shall  see  farther  on  that  another  factor  than  good-living  may 
play  a  causal  part. 

t  The  significance  of  uric  acid  infarcts  in  the  renal  tubules  has 
been  discussed  by  medico-legal  writers. 


14  V A  SO-RENAL  CHANGE. 

In  the  lower  forms  of  life  excretion  seems  as  com- 
paratively simple  as  digestion  ;  and  highly  differentiated 
organs  are  not  found.  But  as  the  ascent  of  creation  is 
made  we  find  the  alimentary  canal  becoming  complex, 
and  bearing  on  it  elaborate  organs ;  just  as  we  see  the 
general  surface  undergoing  modifications.  Certain  areas 
become  specialised  for  the  various  senses.  Other  areas 
possess  merely  general  sensibility.  While  an  involution  of 
the  surface  gives  us  the  urinary  apparatus.  We  see  indeed 
in  the  development  of  the  embyro  the  outer  layer — 
the  epiblast  having  its  medullary  and  epidermal  sublayers  ; 
the  nervous  system  and  the  sensitive  skin.  We  see 
the  inner  ^er  (hypoblast)  giving  us  the  glandular  organs 
of  organic  life.  This  tells  of  descent  from  the  primitive 
endoderm  and  ectoderm  of  the  Gastrula.  The  mesoblast, 
or  middle  layer,  gives  us  the  locomotor  apparatus,  the 
vascular  system,  and  the  genito-urinary  organs.* 

Thus  we  find  a  liver  developing  on  the  alimentary 
canal ;  and  a  portion  of  the  general  excretory  surface  of 
lowly  life  specialised  into  the  urinary  tract.  (That  the 
sweat  and  the  urine  should  possess  much  in  common  is 
readily  intelligible.)  When  these  differentiated  organs 
appear  special  functions  can  be  traced. 

When  we  see  kidneys  developed  we  find  with  them,  as 
a  consequence,  the  urine.  When  urine  first  appears  it 
takes  a  solid  form.  Uric  acid,  as  urates,  belongs  to 
animals  with  a  solid  urine.  The  cold  blooded  reptile  and 
the  bird  of  high  temperature,  alike,  find  their  excremen- 
titious   tissue   waste,  or  albumen-metamorphosis,  in  the 

°  As  we  shall  see,  later  on,  the  uric  acid  formation  runs  alon^  the 
tissue  derived  from  the  different  layers  of  the  early  embryo  in  different 
individuals. 


PRIMAL  DEPARTURES.  15 

form  of  uric  acid.*  But  when  the  mammalia  appear  we 
find  a  fluid  urine,  and  the  form  of  renal  excrement  the 
soluble  urea.  Still  there  remains  a  certain  uric  acid 
formation  in  all  mammals  ;  and  a  small  amount  of  uric 
acid  is  normal  in  the  healthiest  of  men.  In  the  herbivora 
we  find  hippuric  acid  as  a  sort  of  intermediate  form.  The 
urea  formation  is  higher  than  the  uric  acid  formation. 
Urea  is  eminently  soluble.  Uric  acid  is  infinitely  less 
soluble  ;  and  is  a  form  of  excretion  unsuited  to  kidneys 
constructed  to  cast  out  soluble  urinine-salts  in  a  fluid 
urine. 

So  long  as  the  proportion  of  uric  acid  in  solution  is 
small  the  kidneys  remain  uninjured.  But  when — from 
any  cause — the  liver  reverts,  or  falls  back  to  the  uric  acid 
formation,  then  injury  to  the  kidneys  is  the  result.  Years 
ago,  Dr.  George  Johnson,  F.R.S.,  pointed  out  that  kidney 
changes  were  the  results  of  the  products  of  liver-imperfec- 
tion in  many  instances;  and  this  becomes  quite  intelligible 
after  the  foregoing  considerations.  These  comparatively 
insoluble  urates  are  cast  out  by  the  kidney,  or  retained  in 
the  blood.  If  the  former,  the  kidneys  become  injured  in 
time ;  if  the  latter,  these  urates  are  deposited  in  the 
body  as  gout.  Very  often  something  of  both  occurs  ;  and 
so  common  is  the  granular  kidney  (Bright's  Disease) 
found  along  with  gout,  that  the  term  '  gouty  kidney '  has 
been  applied  to  it.  The  association  of  the  two  is  easily 
comprehended. 

The  liver  seems,  to  a  certain  extent,  to  be  worn  out  by 

long,  hard  service,  and  no  longer  capable  of  (practically) 

complete  urea  formation  ;  and  falls  back,  or  reverts,  to  the 

uric  acid  formation — which  is  probably  easier.     What  is 

0  A  small  quantity  of  urea  begins  to  show  itself  in  the  bird. 


1 6  V A  SO-RENAL  CHANGE. 

acquired  by  the  parent  is  often  transmitted  to  the  child  ; 
which  steps  into  its  inheritance — be  the  same  what  it 
may  !  It  may  be  wealth  and  the  uric  acid  diathesis.  It 
may  be  poverty  extending  back  for  generations  with  a 
perfectly  capable  liver.  The  wealth  has  its  drawback;  the 
poverty  its  advantages  ! 

Another  question  to  be  asked  is  this,  '  How  is  it  that 
the  uric  acid '  formation  is  so  marked  in  the  English 
people  ?'  Gout  is  much  more  common  in  England  than 
elsewhere.  Pointing  out  one  day  a  typically  gouty  man 
(an  old  brewery  man)  to  an  American  lady  doctor,  she 
asked,  '  How  is  it  that  we  have  so  little  gout  in  my 
country?'  A  Scotch  medical  man  (himself  gouty)  re- 
plied for  me,  '  Because  neither  in  your  country  nor  mine 
have  we  been  rich  long  enough  to  be  gouty.'  There  was 
no  doubt  a  great  deal  in  this.  But  there  is  something 
more.  The  Anglo-Saxon  has  always  been  fond  of  tooth- 
some morsels.  His  oxen,  his  sheep,  his  pigs,  and  his 
fowls  are  the  best  of  their  kind.  As  a  breeder  he  was 
always  prominent.  And  this  was  as  much  the  outcome 
of  his  palate  as  his  pride  of  ownership.  The  cattle  and 
sheep  of  Continental  Europe  yield  meat  which  will  not 
admit  of  being  served  up  as  the  solid  joint,  the  pride  of 
the  English  matron  who  boasts  of  her  '  plain  roast  and 
boiled.'  It  has  to  be  served  up  in  'fragments,  and  dressed 
as  an  entree.'  And  these  '  greasy  messes  '  (as  the  English 
housewife  contemptuously  terms  them)  are  infinitely  less 
given  to  set  up  gout  than  the  solid  joints — the  chop  and 
steak  of  old  England.  Her  geographical  position,  plus 
the  enterprise  of  her  people,  led  to  the  acquisition  of 
wealth,  which  was  not  dissipated  by  the  march  of  armies 
and  the  waste  of  war,  as  was  the  case  with  every  area  of 


PRIMAL  DEPARTURES.  17 

the  Continent.  It  is  her  prosperity,  taken  in  connection 
with  her  flocks  and  herds,  that  has  made  England  the 
land  of  gout  par  excellence.  It  is  the  extent  of  the  uric 
acid  formation  which  has  given  the  English  physicians 
the  opportunities  of  seeing  vaso-renal  change  of  which  they 
have  availed  themselves.  Of  course,  it  is  seen  in  other 
countries  ;  but  not  to  a  like  extent.  While  the  dietary  of 
the  inhabitants  of  warm  climates  consists  largely  of  hydro- 
carbons, the  beef-eating  Englishman  is  the  gouty  man. 
And  what  part  has  been  played  by  the  form  of  ale- 
brewing  in  England,  it  is  not  possible  to  say  precisely ; 
but  this  fact  is  known,  viz.,  that  many  people  who  pos- 
sess '  livers  '  can  drink  with  impunity  beer  brewed  on  the 
foreign  or  Lager  plan,  who  have  to  abstain  altogether 
from  English  ales — or  take  the  consequences. 

The  first  departure,  then,  in  vaso-renal  change,  physio- 
logically, is  the  reversion  of  the  liver  to  the  lowly  uric 
acid  formation.*  Anatomically,  the  first  departure  is  the 
development  of  connective  tissue,  the  lowliest  material  of 
the  body,  at  the  expense  of  the  other  and  higher  tissues. 

Vaso-motor  Disturbance. — The  main  permanent  features 
of  chronic  Bright's  Disease,  or  vaso-renal  change,  are  a 
tight  artery,  a  large  left  ventricle,  and  the  physiological 
outcome  of  high  arterial  tension,  a  large  bulk  of  urine. 
These  are  well  recognised  clinical  facts,  as  the  works  of 
Marey,  Galabin,  Mahomed,  and  others  have  shown,  as  to 
high  arterial  tension. 

That  the  matcries  morbi  (uric  acid,  in  all  probability,  ac- 

°  The  association  of  the  uric  acid  formation  with  deterioration  is 
shown  by  its  common  occurrence  in  children  of  the  strumous  diathesis  ; 
a  race  of  tissue  inferiority,  with  an  osseous  system,  as  Laycock 
pointed  out,  of  infantile  or  lowly  ethnic  form. 

2 


1 8  VASO-RENAL  CHANGE. 

companied  by  other  forms  of  nitrogenized  waste)  in  the 
blood  irritated  the  vaso-motor  system  of  nerves,  has  been 
recognised  from  the  earliest  day  of  acquaintance  with  this 
morbid  change  as  a  whole.  But  so  far  no  attempt  has 
been  made  (at  least  to  the  writer's  knowledge)  to  asso- 
ciate the  two,  and  see  in  what  relation  they  stand  to  each 
other.  Yet  it  seems  that  the  two  facts  of  the  presence  of 
a  materies  morbi  in  the  blood  and  high  arterial  tension 
stand  in  the  most  instructive  relation  to  each  other.  They 
suggest  that  the  first  consequence  may  be  really  and  truly 
a  self-preservative  depurative  action  on  the  part  of  the 
system.  This  is  a  somewhat  startling  matter  at  first 
sight  ;  but  the  more  it  is  looked  at  the  clearer  and  more 
vivid  does  it  become. 

Uric  acid  is  comparatively  insoluble ;  but  in  ordinary 
normal  amount  it  is  dissolved  in  the  fluid  blood,  and  got 
rid  of  by  the  renal  secretion  without  much  difficulty. 
When  it  exists  in  abnormal  quantity,  a  larger  bulk  of 
urine  is  required  to  get  rid  of  it,  and  cast  it  out.  And 
how  is  this  brought  about  ?  Actions  go  on  in  the  body 
which  seem  to  give  intelligence  to  the  tissues  and  to  cer- 
tain arrangements,  and  in  none  more  strikingly  than  in 
the  attempt  of  the  system  to  clear  itself  of  uric  acid. 
The  increase  in  bulk  of  the  muscular  fibres  of  the  heart  to 
overcome  a  difficulty  has  been  described  as  a  sort  of  spe- 
cies of  intelligence.  The  so-called  intelligence  is  nothing 
more  than  the  self-preservative  power  which  the  body 
possesses  ;  and  which  has  been  developed  through  long 
periods  of  time  in  the  survival  of  the  fittest.  Not  only  is 
it  seen  in  the  main  action  of  the  vaso-renal  change,  but  it 
is  palpable  in  many  of  the  outcomes  which  have  been,  and 
were  regarded  as  diseases  per  se. 


PRIMAL  DEPARTURES.  19 

Dr.  Bence  Jones  described  the  rise  of  temperature  in 
acute  articular  gout,  and  the  inflammation,  as  converting 
the  joints  for  the  time  being  into  so  many  supplementary 
kidneys,  i.e.,  that  the  action  was  a  depurative  action. 
Acute  gout,  secondary  inflammations,  uraemic  vomiting, 
and  uraemic  diarrhoea,  are  marked  instances  of  self-pre- 
servative action  on  the  part  of  the  system,  when  the  blood 
is  surcharged  with  an  excess  of  nitrogenized  waste. 

The  first  effect  of  the  accumulation  of  the  products  of 
albumen  -  metamorphosis  is  to  irritate  the  vaso- motor 
centre,  with  the  result  of  vaso-motor  contraction,  and  a 
rise  in  the  blood-pressure  within  the  arteries.  Or  maybe 
it  is  the  presence  of  impure  blood  in  the  vasa  vasorum 
which  directly  irritates  the  vaso  -  motor  nerves,  with 
resultant  contraction  of  the  arterioles.  The  walls  of  the 
bloodvessels  contract  upon  their  contents ;  the  pressure 
within  the  glomeruli  of  the  kidney  is  increased,  and,  with 
that,  the  bulk  of  the  urine.  A  larger  bulk  of  urine  carries 
with  it  a  larger  quantity  of  the  insoluble  uric  acid.  Just 
as  when  sugar  is  present  in  the  blood  in  excess  thirst  is 
the  result ;  and  the  thirst  secures  the  imbibition  of  water, 
which  washes  the  offending  sugar  away.  When  the  liver 
is  out  of  order,  malproducts  are  present  in  the  blood,  with 
the  resultant  consequences  of  loss  of  appetite,  which  eases 
its  burden ;  and  thirst,  which  causes  fluids  to  be  taken  in 
considerable  quantities,  and  so  the  peccant  matter  is  swept 
away.  These  actions  no  more  involve  intelligence  than 
do  hunger  and  thirst.  They  are  illustrations  of  the 
capacity  of  the  system  within  certain  limits  to  take  care 
of  itself. 

In  what  other  way  could  the  system  increase  the  bulk 
of  urine  than  by  raising  the  blood-pressure  in  the  arteries  ? 

2 — 2 


2o  VASO-RENAL  CHANGE. 

By  no  other  means  that  we  know  of  in  the  present  state 
of  our  knowledge !  Thirst  leading  to  the  drinking  of 
fluids  no  doubt  raises  the  blood-pressure  in  the  arterial 
system  until  the  free  flow  out  by  the  kidneys  once  more 
balances  matters.  By  its  irritant  or  stimulant  effect  upon 
the  vaso-motor  centre,  uric  acid  is  cast  out  of  the  blood. 

This  view  of  the  long  complex  process,  lasting  often 
over  years  and  many  years,  is  highly  instructive  as  to  the 
production  of  many  maladies,  which  are  the  direct  out- 
come of  this  attempt  upon  the  part  of  the  system  to  right 
itself;  to  free  itself  from  the  presence  of  uric  acid — the 
primitive  urine-stuff  which  does  not  rightly  belong  to  the 
mammalian  body  with  a  fluid  urine. 

Pathology  is  physiology  modified ;  and  when  uric  acid 
is  circulating  in  the  blood-current,  the  system  possesses  a 
means  of  getting  rid  of  it.  But  the  effort  entails  many 
morbid  changes,  and  departures  from  health  as  the  out- 
comes thereof;  of  which  some  account  will  be  given  in 
the  following  pages. 

But  while  recognising  the  broad  fact  that  high  arterial 
tension  and  a  copious  urine  are  characteristics  of  the 
vaso-renal  change,  there  are  variations  therefrom,  accord- 
ing to  certain  modifying  circumstances,  to  be  considered 
shortly.  That  uric  acid  accumulates  in  the  blood,  and  is 
removed  by  an  attack  of  acute  gout,  the  observations  of 
Garrod  show  conclusively.  The  uric  acid  seems  to  be 
broken  up  into  urea  and  oxalic  acid,  which  escape  by  the 
kidneys.  How  far  the  system  possesses  the  power  of 
breaking  up  uric  acid  into  soluble  matters,  and  so  clearing 
itself,  is  a  matter  on  which  much  darkness  still  rests. 
Why  the  change  in  arterial  tension  is  less  marked  in 
some  persons  than  others,  and,  with  that,  its  resultant 


PRIMAL  DEPARTURES.  21 

phenomena,  may  depend  upon  this  breaking  up  of  uric 
acid.  The  system  may  possess  several  means  of  getting 
rid  of  uric  acid  ;  and  one  be  more  operative  in  one  person, 
while  another  takes  the  lead  in  another  person  of  the  uric 
acid  formation.  For  certainly  we  see  the  change  as 
regards  the  vascular  system  more  pronounced  in  some 
persons  than  in  others.  In  a  complex  matter  involving 
many  outcomes  —  which  the  vaso  -  renal  change  most 
certainly  is  —  no  one  individual  can  manifest  all  the 
phenomena  ;  because  some  are  antagonistic  to  others,  as 
we  shall  see.  Still,  high  arterial  tension  is  the  condition 
par  excellence  in  vaso-renal  change.  As  the  kidneys  become 
extensively  injured,  the  output  of  both  the  soluble  urea 
and  the  insoluble  uric  acid  falls,  and  the  urine  is  of  low 
specific  gravity ;  while  the  blood  is  imperfectly  depurated. 
In  other  words,  the  power  of  the  system  to  secure  blood- 
depuration  is  waning;  just  as  the  hypertrophy  of  the  left 
ventricle,  to  meet  the  high  arterial  tension,  wears  out  in 
time — and  the  heart  fails  in  its  energy.  Indeed,  some 
individuals  die  with  marked  kidney-changes ;  while  in 
others,  again,  it  is  the  heart  which  attracts  the  attention, 
and  heart-failure  which  is  the  cause  of  death,  and  not  the 
kidney. 

Whatever  objections  may  be  taken  to  the  view  that  the 
rise  of  arterial  tension  is  a  self-preservative  action  of  the 
system  as  regards  the  later  stages  of  vaso-renal  change, 
there  seem  valid  grounds  for  so  regarding  it  as  a  primal 
departure,  at  any  rate. 

That  diminished  output,  in  addition  to  a  tendency  to 
uric  acid  formation,  may  be  essential  to  accumulation  in 
the  blood,  and  excitation  of  the  vaso-motor  system,  is 
probable.      As  Dr.  W.   H.  Dickenson   informs  me  that 


22  VASO-RENAL  CHANGE. 

'  Disease  of  the  liver,  without  disease  of  the  kidney,  such 
as  cirrhosis,  which  is  presumably  associated  with  excess 
of  uric  acid  in  the  blood,  certainly  does  not  cause  hyper- 
trophy of  the  heart  or  arterial  thickening.'  If  the  kidneys, 
then,  cast  out  uric  acid,  the  accumulation  in  the  blood, 
with  its  consequences,  does  not  exist.  Sir.  Wm.  Roberts, 
M.D.,  thinks  '  that  in  "  high  tension  "  the  blood  contains 
much  "  dirt  " — of  very  varied  character— not  merely  uric 
acid,  but  also  much  else  that  would  be  better  cast  out  by 
the  excretory  channels.'  That  uric  acid  is  accompanied 
by  other  members  of  the  descending  series  of  albumen- 
metamorphosis  in  the  accumulation  of  waste  matter  in 
the  blood,  has  been  suggested  already  in  this  chapter. 

Direct  experiment  alone  can  positively  determine  the 
association  of  excess  of  uric  acid  in  the  blood  with  high 
arterial  tension  and  increased  bulk  of  urine.  I  have  not 
been  able  to  hear  of  any  such  experimentation.  But 
Ustimowitsch  (Ludwig's  '  Arbeiten '  for  1870,  p.  212) 
found  that  the  injection  of  urea  into  the  veins  of  a  dog 
invariably  caused  a  rise  of  blood-pressure.  For  this  in- 
formation I  have  to  thank  Dr.  Lauder  Brunton,  F.R.S., 
who  thinks  it  possible  that  it  may  be  found  that  uric  acid 
possesses  the  same  property,  even  to  a  higher  degree. 

COMMENTS     UPON     THE     DEPURATIVE     THEORY,     BY 
DR.    F.    W.    MOTT. 

The  theory  that  the  diuresis  of  chronic  Bright's  Disease, 
or  vaso-renal  change,  is  a  depurative  action  on  the  part 
of  the  economy,  is  an  attractive  one.  But  it  is  a  mere 
speculation  that  the  uric  acid  accumulation  in  the  blood 
stimulates  the  vaso-motor  centre,  thus  raising  the  general 
blood-pressure,  and  causing  an  increased  flow  of  urine. 


PRIMAL  DEPARTURES.  23 

The  notion  that  the  diuresis  which  occurs  causes  more 
of  the  insoluble  uric  acid  to  be  washed  out,  forming  a  self- 
adjusting  mechanism  for  its  elimination,  is,  unfortunately, 
unsupported  either  by  clinical  experience  or  by  physio- 
logical investigation  ;  although  there  are  many  facts  in 
favour  of  a  depurative  theory  when  applied  to  the  soluble 
nitrogenous  waste-products,  such  as  urea. 

Briicke,  in  his  lectures,  was  the  first,  I  believe,  to  suggest 
that  the  abundant  diuresis  met  with  in  many  cases  of 
hydro-nephrosis  was  a  physiological  compensatory  action, 
by  which  the  urinary  salts  were  washed  out. 

Cohnheim,  by  his  experiments,  has  proved  that  the 
composition  of  the  blood  has  a  marked  influence  on  the 
renal  circulation.  The  injection  of  urea  into  the  circula- 
tion of  an  animal  causes  decided  increase  in  the  amount 
of  blood  flowing  to  the  kidneys,  and  an  increased  flow  of 
urine.  From  these  experiments  he  is  of  opinion  that  the 
degree  of  dilatation  of  the  smaller  renal  arteries  is  de- 
pendent upon  the  amount  of  urinary  products  which  the 
blood  happens  to  contain  ;  consequently,  when  parts  of 
the  renal  cortex  have  undergone  destruction,  as  in  chronic 
Bright's  Disease,  there  will  be  a  dilatation  of  the  small 
renal  arteries  of  the  remaining  healthy  portions  of  the 
organs,  allowing  a  large  quantity  of  blood  still  to  circulate 
through  them  ;  this  dilatation  of  the  small  renal  vessels 
being  induced  by  a  constant  tendency  to  accumulation  of 
urea,  and  other  nitrogenous  waste-products,  in  the  blood. 
The  experiments  to  which  I  have  already  alluded  support 
strongly  the  theory  that  a  physiological  compensation  is 
effected  by  a  dilatation  of  the  small  renal  vessels. 

The  amount  of  urine  secreted  by  the  kidneys  is  de- 
pendent upon  the  pressure  in  the  glomeruli.     This  pres- 


24  VA SO-RENAL  CHANGE. 

sure  may  undoubtedly  be  raised  by  any  cause  which  leads 
to  an  increased  flow  of  blood  through  them.  Conse- 
quently those  glomeruli  which  remain  healthy  will  receive 
relatively  a  very  large  quantity  of  blood  at  a  very  high 
pressure  for  the  following  reasons :  A  hypertrophied  left 
ventricle,  acting  with  increased  force,  drives  into  the  renal 
arteries  cf  the  small  gouty  kidney  as  much  blood  as  the 
normal  heart  drives  into  the  renal  arteries  of  the  healthy 
kidneys ;  the  difference  being  that  the  pressure  in  the 
former  is  greater  than  in  the  latter. 

But  if  the  same  volume  of  blood  is  forced  into  the  renal 
arteries  of  the  atrophied  kidneys,  as  into  those  of  the 
healthy  kidneys,  the  effect  will  be  that  the  pressure  and 
the  rate  of  flow  of  the  blood  in  those  glomeruli  which 
remain  healthy  in  the  contracted  kidney  will  be  very  much 
greater  than  in  the  glomeruli  of  the  healthy  organ.  This 
exaggerated  blood-pressure  in  the  glomeruli  of  the  con- 
tracted kidney  will  have  the  following  effects  :  An  in- 
creased flow  of  urine  takes  place,  which  will  serve  to  wash 
out  the  nitrogenous  waste-products,  especially  such  as  are 
sokible;  but  at  the  same  time  the  organ  will  suffer  from 
this  continuous  high  pressure,  and  the  renal  inadequacy 
must  of  necessity  be  a  progressive  one. 

This  physiological  compensation,  however,  can  only  be 
effectual  when  combined  with  the  maintenance  of  a  cor- 
responding resistance  in  all  other  parts  of  the  arterial 
system,  such  as  we  find  to  exist  in  vaso-renal  change,  or 
Bright's  Disease,  even  in  its  earliest  stages.  If  it  were  not 
for  this  increased  peripheral  resistance,  induced  either  by 
obstruction  to  the  flow  of  blood  through  the  capillaries,  or 
by  arterial  spasm,  the  effect  of  the  dilatation  of  the  renal 
arteries,  brought  about  by  the  influence  of  the  accumulated 


PRIMAL  DEPARTURES.  25 

urinary  salts  in  the  blood,  would  be  in  a  great  measure 
nullified.  This  is  because  the  blood  would  be  determined 
away  in  the  direction  of  least  resistance,  and  consequently 
less  blood  would  flow  to  the  kidney.  Really,  the  com- 
pensatory mechanism  allows  a  large  quantity  of  blood  to 
pass  through  an  arterial  area  of  a  very  much  diminished 
capacity,  the  result  being  a  rapid  flow  at  a  high  pressure 
through  the  glomeruli,  and  resultant  polyuria. 

While  admitting  that  the  augmented  flow  of  urine 
which  occurs  in  chronic  Bright's  Disease,  due  to  the 
contracted  kidney,  has  many  arguments  in  its  favour, 
I  hardly  think  that  this  theory  of  physiological  compensa- 
tion can  be  applied  in  the  way  stated  by  Dr.  Fothergill. 
Having  previously  suggested  this  theory  in  somewhat 
different  words,  I  have  considered  it  untenable  for  the 
following  reasons  : — 

It  is  as  yet  unsupported  by  experimental  investigations  ; 
or,  so  far  as  I  know,  by  clinical  experience  and  observation. 

The  following  evidence  appears  contrary  to  the  uric 
acid  hypothesis.  Uric  acid  is  an  extremely  insoluble  salt, 
only  1  in  15,000  parts  being  dissolved  by  water,  con- 
sequently five  pints  of  water  will  only  take  up  about 
3j  grains.  If  the  water  be  made  acid,  it  would  take  up 
still  less  ;  therefore  the  amount  of  uric  acid  eliminated  by 
the  kidneys  depends  not  so  much  upon  the  quantity 
of  water  which,  is  excreted,  as  upon  the  degree  of  acidity, 
and  the  condition  in  which  the  uric  acid  exists  in  the 
blood. 

As  to  the  cause  of  the  accumulation  of  uric  acid  in  the 
blood  in  gout,  there  are  three  views : 

1st.  An  increased  formation  of  uric  acid,  owing  to 
imperfect  oxidation. 


26  VASO-RENAL  CHANGE. 

2nd.  A  defective  excretory  power  of  the  kidney  for  the 
elimination  of  uric  acid. 

3rd.  An  accumulation  in  the  blood  of  uric  acid,  owing 
to  a  deficiency  in  the  alkalinity  of  the  blood,  rendering 
the  uric  acid  more  insoluble,  and  therefore  more  difficult 
to  eliminate.  This  deficient  alkalinity  of  the  blood  has 
been  attributed  to  an  increased  formation  of  lactic  and 
volatile  fatty  acids  which  are  produced  by  digestive 
disturbances,  so  common  in  gouty  people.  The  last  view 
is  the  most  plausible  from  clinical  and  experimental 
observations. 

Sir  Wm.  Roberts  has  shown  in  health  that  the  amount 
of  uric  acid  excreted  by  the  kidneys  is  three  times  as 
great  during  the  alkaline  tide  following  a  meal  than  at 
other  times.  Again,  the  administration  of  potash  and 
lithia  salts  in  the  treatment  of  gout  supports  this 
view. 

If  the  uric  acid  while  circulating  in  the  blood  acts  in 
the  way  suggested  on  the  vaso-motor  centre,  causing  a 
rise  of  blood-pressure,  the  gouty  patient  should  from  the 
very  first  pass  large  quantities  of  water.  On  the  contrary, 
lithasmia  is  usually  associated  with  scanty  high-coloured 
urine  depositing  an  abundance  of  lithates,  not  on  account 
of  the  increase  in  the  proportion  of  uric  acid  eliminated, 
for  that  is  usually  diminished,  but  being  thrown  down,  on 
the  urine  cooling,  on  account  of  its  acidity. 

As  the  disease  progresses,  the  quantity  of  uric  acid 
eliminated  per  diem  diminishes,  and  finally  in  the  late 
stages  may  be  absent  altogether.  Now  it  is  particularly 
with  late  stages  of  gout,  when  the  kidneys  are  small  and 
granular,  owing  to  the  cirrhotic  changes  in  their  structure, 
that  the  increased  flow  of  urine  occurs. 


PRIMAL  DEPARTURES.  27 

This,  then,  would  be  the  period  when  little  or  no  uric 
acid  is  eliminated.  It  appears  to  me  that  another  means 
is  adopted  by  the  economy  for  purifying  the  blood  of  this 
waste-product.  As  soon  as  the  uric  acid  has  accumulated 
to  a  certain  extent  it  combines  with  soda  to  form  urate  of 
soda  ;  and  this  insoluble  salt  is  deposited  in  a  crystalline 
form  from  the  lymph  in  the  cartilages  of  the  small  joints. 
Later  on  in  the  disease,  it  may  be  detected  in  the  sub- 
stance of  the  kidneys  between  the  renal  tubules,  thus 
leading  to  degenerative  changes  in  the  organs.  After 
a  paroxysm  of  gout  the  patient  is  relieved,  and  the  blood 
is  to  a  great  extent  purified.  In  the  intervals  of  the 
paroxysms,  uric  acid  is  accumulating  in  the  blood;  con- 
sequently, if  we  accept  this  hypothesis,  there  should  be  a 
progressively  increasing  exciting  cause  acting  upon  the 
vaso-motor  centre,  with  a  corresponding  increase  of 
arterial  tension  and  flow  of  urine.     But  does  this  occur  ? 

No  doubt  the  retained  materies  morbi  does  increase 
peripheral  resistance  either  by  the  effect  it  produces  on 
the  walls  of  the  capillaries,  or  by  the  stimulation  of  the 
vaso-motor  nerves  causing  contraction  of  the  arterioles. 

How  far  this  is  due  to  the  uric  acid,  and  not  to  the  renal 
inadequacy,  cannot  be  determined ;  but  this  much  is 
certain,  that  in  cases  of  obstruction  of  the  ureters  and 
production  of  the  obstructive  form  of  uraemia,  we  have 
no  evidence  of  high-tension  pulse,  although  the  materies 
morbi  are  accumulating. 

Again,  in  the  pre-albuminuric  stage  of  scarlatinal 
nephritis,  we  have  high-tension  pulse  before  any  sign 
of  renal  disease  appears.  Gout  is,  in  most  cases,  accom- 
panied, or  followed,  by  renal  disease.  We  cannot  prove 
that  the  high-tension  pulse  and  the  enlarged  left  ventricle 


2S  VASO-RENAL  CHANGE. 

would  exist  were  it  not  for  the  latter  complication;  and 
as  all  forms  of  renal  change,  except  the  lardaceous,  are 
accompanied  from  the  very  earliest  condition  by  a  high- 
tension  pulse,  it  will  be  quite  impossible  to  attribute 
with  any  degree  of  certainty  the  increased  peripheral 
resistance  entirely  to  the  circulation  of  waste-products  in 
the  blood. 

In  many  cases  of  leukaemia  there  is  a  considerable  in- 
crease of  the  uric  acid  eliminated  by  the  kidneys,  perhaps 
induced  by  defective  oxidation  processes  ;  yet  there  is  no 
increase  of  arterial  tension  or  of  the  urine  passed. 

The  increased  flow  of  urine  only  occurs  when,  owing 
to  the  degenerative  changes  in  the  kidneys,  there  is  a 
tendency  to  the  accumulation  of  urea  in  the  blood  ;  and  if 
we  term  Cohnheim's  compensatory  a  '  depurative  '  theory 
to  rid  the  system  of  the  waste-product,  more  especially 
the  soluble  urea,  I  am  of  opinion  that  there  is  very  much 
to  be  said  in  its  favour ;  but  this  is  totally  different  from 
the  hypothesis  which  I  have  been  asked  by  Dr.  Fothergill 
to  criticize. 

These  comments  are  valuable  in  demonstrating  how 
much  we  have  yet  to  learn  before  a  satisfactory  hypothesis 
can  be  broached  as  to  the  association  of  high  arterial 
tension  with  the  accumulation  of  products  of  albumen- 
metamorphosis  in  the  blood.  The  subject  is  well  worth 
investigation  by  clinical  observers,  as  well  as  by  experi- 
mental physiologists,  who  have  found  urea  to  raise  the 
blood-pressure  in  the  arteries.  Whether  my  own  hypo- 
thesis is  unwarranted  by  facts,  as  Dr.  Mott  holds,  and 
Cohnheim's  is  the  correct  solution;  or  both  are  insufficient, 
and  the  correct  hypothesis  has  yet  to  be  found  ;  it  is  my 


PRIMAL  DEPARTURES.  29 

firm  conviction  that  ultimately  the  high  arterial  tension  of 
vaso-motor  change  will  be  found  to  be  a  part  of  the  self- 
protective  action  on  the  part  of  the  organism  ;  which, 
'  traced  from  within  its  inmost  centre  to  its  outmost  skin,' 
the  vaso-renal  change  is  from  beginning  to  end. 

Growth  of  Connective  Tissue. — In  order  to  comprehend 
clearly  this  growth  of  connective  tissue  to  the  detriment 
of  the  normal  and  higher  tissues,  it  becomes  desirable  to 
glance  at  the  tissue-development  of  the  embryo.  At  a 
very  early  period  three  layers  are  seen  :  (1)  The  outer  or 
epiblast,  which  furnishes  the  central  nervous  system  and 
the  sensitive  epidermis — in  other  words,  the  means  by 
which  the  organism  is  in  communication  with  its  environ- 
ment ;  (2)  the  inner,  or  hypoblast,  which  gives  the 
glandular  apparatus  of  organic  life,  i.e.,  the  glandular 
organs  which  lie  along  and  debouch  into  the  alimentary 
canal ;  while  (3)  the  middle  layer,  or  mesoblast,  furnishes 
the  locomotor  apparatus,  bone,  muscle  and  cartilage,  the 
vascular  system,  and  the  genito-urinary  organs.  From 
the  wander-cells  of  the  mesoblast  springs  the  lowly  con- 
nective tissue,  or  packing  material  of  the  body,  which 
holds  the  other  tissues  together. 

As  the  embryo  develops,  we  see  how  from  the  epiblast 
the  axis-cylinder  of  a  nerve  projects,  while  the  mesoblast 
throws  round  it  nerve-sheath  and  bloodvessels.  From 
the  hypoblast  we  can  see  the  glandular  structure  of  the 
liver  gradually  forming,  while  the  mesoblast  is  supplying 
the  fibrous  stroma,  or  framework  of  the  gland,  and  the 
bloodvessels;  which  not  only  feed  the  glandular  structure, 
but  which  bring  to  it  at  a  later  day  the  material  upon 
which  it  exercises  its  proper  function.  The  different 
tissues  are  woven  together,  the  elements  of  each  remain- 


3° 


VA  SO-RENA  L  CHA  NGE. 


ing  distinct.  There  is  an  interweaving  ;  but  not  a  blend- 
ing, or  fusing  one  into  another. 

The  following  engraving  is  taken  from  the  '  Elements 
of  Embryology,'  by  Foster  and  Balfour.  It  represents 
the  development  of  the  eye  of  a  rabbit. 

'  In  the  invagination  of  the  lens  a  thin  layer  of  maeso- 
blast  is  carried  before  it,  and  is  thus  transported  into  the 


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Yig,  i. — Section  through  the  Eye  of  a  Rabbit  Embryo  of  about 
Twelve  Days,  c,  Epithelium  of  cornea  ;  /,  lens  ;  m,  e,  c,  mesoblast 
growing  in  from  the  side  to  form  the  cornea  ;  rt,  retina  ;  a,  c,  r, 
arteria  centralis  retinae  ;  op,  n,  optic  nerve. 


cavity  of  the  vitreous  humour.  In  the  folding  in  of  the 
optic  vesicle,  which  accompanies  the  formation  of  the 
lens,  the  optic  nerve  is  included,  and  on  the  development 
of  the  cavity  of  the  vitreous  humour  an  artery,  running  in 
the  fold  of  the  optic  nerve,  passes  through  the  choroid 


PRIMAL  DEPARTURES.  31 

slit  into  the  cavity  of  the  vitreous  humour.  The  sides  of 
the  optic  nerve  subsequently  bend  over,  and  completely 
envelop  this  artery,  which  gives  off  branches  to  the 
retina,  and  becomes  known  as  the  arteria  centralis  retina.' 

The  consideration  of  this  engraving  teaches  us  how  the 
different  structures  are  built  up  together  like  a  house  of 
various  materials,  while  the  connective  tissue  holds  all 
together.  In  the  vaso-renal  change  we  find  the  connective 
tissue  encroaching  upon  the  other  tissues.  It  grows 
luxuriantly  at  their  expense.  The  high  blood-pressure, 
which  is  found  more  or  less  in  all  cases  of  vaso-renal 
changes,  is  accompanied,  or  followed,  by  a  growth  of  con- 
nective tissue.  We  find  it  in  the  arterial  walls,  rendering 
them  in  time  rigid,  inelastic  and  brittle — from  whence 
arise  many  of  the  diseases  which  spring  from  arterial 
degeneration  (atheroma),  as  apoplexy  and  aneurysm.  We 
see  it  extending  through  the  kidney,  gradually  and  slowly 
progressing ;  till  at  last  the  organs  are  so  extensively 
injured  that  they  can  no  longer  do  their  work,  and  the 
organism  perishes. 

Holding  the  urates  within  it,  the  blood  acts  as  an 
irritant  upon  kidneys  constructed  for  the  elimination  of 
soluble  urea. 

'  In  studying  the  causes  of  Bright's  Disease,  we  have  to 
look  for  an  irritant  ;  and  it  is  here  important  to  observe, 
in  the  first  place,  that  the  inflammatory  manifestations 
occur  in  both  kidneys  ;  and,  although  on  examining  the 
kidneys  in  detail,  these  manifestations  will  be  found  to 
present  themselves  in  innumerable  minute  foci,  and  to 
confine  themselves  for  the  most  part  to  the  cortex,  yet 
they  do  not  affect  a  few  definite  areas,  but  are  diffused 
over  the  length  and  breadth  of  the  organ.     These  facts 


32  VASO-RENAL  CHANGE. 

indicate  that  the  irritant  is  carried  to  the  kidneys  by  the 
blood,  and  is  distributed  by  the  blood.  As  the  blood  is 
primarily  distributed  to  the  cortex,  and  as  the  cortex  con- 
tains the  more  active  secreting  tissue  of  the  organ,  it  so 
happens  that  the  inflammatory  manifestations  occur  almost 
exclusively  there.' 

In  the  various  cases  of  Bright's  Disease  we  do  not  find 
the  various  constituents  of  the  kidney  tissue  equally  en- 
gaged ;  and  it  is  necessary  in  studying  the  causation  to 
refer  to  this  matter.  In  the  kidney  we  have,  as  the  main 
constituents,  the  bloodvessels,  the  secreting  tissue  (con- 
sisting of  the  glomeruli  and  the  tubules,  with  their  epi- 
thelium), and  the  connective  tissue.  It  is  not  impossible 
that  an  irritant  brought  to  the  kidneys  by  the  blood  may 
show  a  predilection  for  the  renal  epithelium  on  the  one 
hand,  or  the  connective  tissue  on  the  other.  But  it  seems 
more  likely  that  in  the  majority  of  cases  it  will  act  on 
both  at  the  same  time.  We  have  already  had  several 
opportunities  of  observing  that  chronic  inflammations 
very  commonly  produce  inflammatory  new  formations  in 
the  connective  tissue,  and  the  kidney  forms  no  exception 
in  this  respect.  It  may  be  said,  therefore,  that  for  the 
most  part  irritants  which  act  through  long  periods,  and 
with  little  intensity,  produce  a  chronic  inflammation 
mainly  of  the  connective  tissue.  On  the  other  hand, 
irritants  which  act  intensely,  so  as  to  produce  acute  in- 
flammation, while  they  produce  the  usual  changes  in  the 
bloodvessels  which  we  have  seen  to  occur  in  acute  in- 
flammations, affect  mainly  the  epithelium  of  the  uriniferous 
tubules.  It  may  therefore  be  said  that  acute  inflamma- 
tions are  parenchymatous,  while  chronic  inflammations  are 
interstitial. 


PRIMAL  DEPARTURES.  33 

This  distinction,  however,  cannot  be  rigidly  carried  out. 
There  are  some  acute  inflammations  which  affect  the 
interstitial  connective  tissue  even  more  than  the  secreting 
epithelium  ;  and  in  all  acute  inflammations  which  are 
somewhat  prolonged,  the  connective  tissue  is  involved. 
On  the  other  hand,  inflammations  which  have  begun 
acutely,  frequently  become  chronic,  or  subacute  ;  and  in 
them,  while  the  epithelium  continues  to  show  marked 
changes,  the  interstitial  tissue  always  shows  distinct  in- 
flammatory proliferation  ('  Manual  of  Pathology,'  by 
Coats). 

Dr.  Coats  here  differentiates  in  a  lucid  and  instructive 
manner  betwixt  the  acute  inflammation  of  the  kidney, 
which,  commencing  in  the  tubules,  involves  in  time  the 
connective  tissue  (which  might  fairly  enough  be  spoken  of 
as  'Chronic  Bright's  Disease');  and  the  interstitial  chronic 
inflammation  due  to  an  irritant  borne  upon  the  blood- 
current,  which,  though  affecting  other  structures,  is  '  a 
chronic  inflammation  mainly  of  the  connective  tissue  ' 
(and  which  would  be  more  correctly  spoken  of  as  the 
renal  factor  of  vaso-renal  change).  Of  course  we  can 
easily  see  how  primary  renal  disease,  by  causing  imperfect 
blood-depuration,  may  in  some  cases  be  the  starting-point 
of  vaso-renal  change.  With  primary  renal  disease,  how- 
ever, we  are  not  here  concerned. 

The  accompanying  drawing  shows  very  clearly  the 
formation  of  one  of  these  minute  foci  located  in  the 
cortical  portion  of  the  kidney.  The  overgrowth  of  this 
lowly  connective  tissue  would  matter  comparatively  little 
if  it  merely  grew,  and  added  to  the  bulk  of  a  viscus.  But 
unfortunately  all  connective  tissue  of  pathological  origin 
carries  with  it  an  innate  tendency  to  contract ;  as  is  seen 

3 


34 


V A  SO-RENAL  CHANGE. 


from  the  cicatrix  of  a  burn  downwards.  It  is  this  con- 
traction which  compresses  the  other  tissues  within  its 
remorseless  clutch.  A  lush  growth  of  connective  tissue 
involves  contraction  ;  and,  with  that,  the  compression  of 
normal  tissues  to  the  point  of  their  destruction,  as  regards 
their  functional  capacity.  The  piece  of  imprisoned  normal 
tissue  is  lost  for  ever  to  the  rest  of  the  viscus.     It  is  like 


Fig.  2. — Section  of  the  Cortex  of  an  Advanced  Granular  Contracted 
Kidney. — The  capsule,  a,  is  thickened,  and  elevations  and  depressions 
are  seen,  the  latter  corresponding  to  the  situation  of  the  glomeruli, 
around  which  the  fibrous  tissue,  b,  is  more  abundant,  c,  Glomeruli ; 
d,  vessel  with  thickened  walls  ;  e.  small  cyst  forming  f,  tubules, 
many  being  atrophied.     Magnifications,  80  diameters. 

the  garrison  of  a  beleaguered  fortress,  hopelessly  sur- 
rounded and  cut  off  from  the  retreating  main  army,  which 
it  can  never  rejoin. 

In  the  engraving  this  invasion  of  new  connective  tissue 
is  well  seen  at  a.  The  tubules  are  compressed,  and  the 
glomeruli  obliterated,  while  the  contraction  has  dragged 
in  the  capsule  of  the  kidney,  causing  that  granulation  of 
the  surface  which  gave  rise  to  the  term  '  granular  kidney.' 


PRIMAL  DEPARTURES.  35 

At  b  the  growth  can  be  seen  around  a  glomerulus  not  yet 
compressed.  At  c,  the  compressing  process  has  com- 
menced. At  d  is  clearly  seen  the  thickening  of  the  arterial 
wall  by  a  development  of  connective  tissue  within  it.  At 
c  is  a  tiny  cyst  formed  from  an  occluded  urinary  tubule. 
The  work  of  destruction  is  going  on  underneath  the  eye. 
A  portion  of  the  kidney  has  been  destroyed.  The  work  of 
spoliation  is  progressing  apace.  It  is  merely  a  question  of 
time.  Sooner  or  later,  according  to  the  intensity  of  the 
irritant,  the  work  of  destruction  will  be  practically  com- 
plete; and  the  kidney  injured,  until  it  is  unequal  to  keeping 
the  system  alive.  The  intensity  of  the  irritant  will  be 
profoundly  influenced  by  the  extent  to  which  the  uric  acid 
formation  exists. 

The  greater  and  the  more  extensive  this  destruction  of 
the  kidney,  the  less  perfect  will  be  that  depuration  of  the 
blood  which  is  the  special  work  of  the  kidney.  And  with 
this,  as  we  shall  see  hereafter,  those  secondary  inflamma- 
tions of  serous  surfaces  and  elsewhere,  which  constitute 
one  of  the  many  dangers  that  overhang  those  who  are  the 
subjects  of  vaso-renal  change, — when  this  morbid  condi- 
tion of  the  blood  becomes  pronounced  and  permanent. 

While  the  growth  of  connective  tissue  is  the  essential 
anatomical  departure  from  health,  the  condition  of  the 
blood  starts  up  changes  in  the  circulation.  The  impure 
blood  excites,  as  we  have  seen,  peripheral  arteriole  spasm ; 
and  this  leads  to  an  obstruction  to  the  blood-flow  out  of 
the  arteries.  This  damming  of  the  blood  in  the  arteries 
opposes  an  obstruction  to  the  outflow  of  blood  from  the 
left  ventricle  on  its  systole  ;  and  this  in  turn  leads  to 
hypertrophy  of  the  left  ventricle.  This  condition  lasts 
usually  many  years  ;  and  is  compatible  with  great  energy, 

3—2 


36  VA SO-RENAL  CHANGE. 

mental  and  bodily.  But  the  infiltration  of  connective 
tissue  growth  into  the  wall  lessens  its  elasticity,  and  in- 
cludes the  aorta.  The  growth  is  often  very  marked  in  the 
coronary  arteries,  which  become  tortuous,  by  which  the 
blood-current  is  slowed  ;  while  the  reduction  of  the  bore, 
or  lumen,  of  the  arteries,  by  growth  of  connective  tissue  in 
the  inner  coat,  leads  to  a  lessened  blood-flow.  Between 
the  two  the  heart  is  imperfectly  fed,  and  a  process  of  fatty 
degeneration  in  the  ill-nourished  muscular  wall  is  set  on 
foot ;  which  leads,  in  its  turn,  to  failure  of  the  heart's 
action,  and  with  this,  following  in  its  wrake,  the  final  scenes 
of  this  long  pathological  process. 

Whether  it  is  the  wall  of  the  arteries  of  the  heart,  or 
the  kidney, — the  growth  of  connective  tissue  is  the  ruin  of 
both  alike  in  time. 


CHAPTER  III. 

FIRST    STAGE. 

The  Norse  Type  {Changes  in  the  Tissues  of  the  Mesoblast) :  Changes 
in  the  Vascular  System — Joint-Gout — Rheumatism — Chronic  Bron- 
chitis— Emphysema — Eczema — Secondary  Valvular  Disease  in  the 
Heart. 

The  Neurotic,  or  Arab  Type  {Changes  in  the  Tissues  of  the  Hypo- 
blast and  Epiblast)  :  Digestive  Troubles — Biliousness — Skin  Affec- 
tions—  Migraine — Mental  Phenomena — Cardiac  Neuroses. 

Some  Practical  Points. 

Several  points  of  interest  will  reveal  themselves  as  the 
progress  of  the  morbid  sequences  of  liver-reversion  is 
considered.  Whether  there  are  other  products  of  faulty 
assimilation,  or  earlier  members  of  the  descending  series 
of  albumen- metamorphosis — which  commences  in  kreatin 
and  kreatinin,  and  ends  in  uric  acid  and  urea — playing 
a  part  in  the  vaso-renal  change,  or  not,  it  is  impossible  to 
say.  But  certainly  there  is  a  reversion  to  the  uric  acid 
formation,  with  the  attempt  of  the  system  to  cast 
it  out. 

Urates  circulating  in  the  blood  set  up  a  vast  variety  of 
morbid  actions  and  processes  ;  of  which  the  first  to  be 
observed  were  such  as  appealed  to  the  eye.  Cheiragra 
and  podagra,  with  tophi  on  the  ears,  were  matters  which 
could  readily  be  determined  as  to  diagnosis.     Then  the 


38  VA SO-RENAL  CHANGE. 

association  of  these  with  certain  subjective  feelings  and 
moods  was  recognised,  as  Sydenham  pointed  out.  Irri- 
tability of  temper  and  depression  of  spirits  were  the 
concomitants  of  a  fit  of  acute  gout ;  while,  on  the  other 
hand,  he  found  that  whenever  he  applied  himself  to  literary 
work  he  brought  on  the  gout.  The  Earl  of  Chatham 
was  positively  melancholic  for  the  space  of  two  years, 
and  retired  from  public  life,  till  a  fit  of  gout  restored  him 
to  his  wonted  mental  state  and  enabled  him  to  return  to 
his  place  in  the  legislature. 

Then  it  was  observed  that  the  vascular  system  was 
involved,  when  the  stethoscope  brought  cardiac  murmurs 
within  the  reach  of  practical  medicine.  The  fact  that 
eczema  was  linked  with  gouty  states  had  long  been 
recognised.  Bronchitis,  with  a  tendency  to  linger  in  a 
chronic  form,  was  noted  as  a  concomitant  of  gout. 
Rheumatism  was  frequent  in  men  of  the  gouty  build  and 
diathesis. 

Now  it  is  at  once  curious  and  interesting,  as  well  as 
instructive,  to  see  how  these  manifestations  of  gout  are 
found  in  the  structures  derived  from  the  mesoblast,  or 
middle  layer  of  early  foetal  life.  As  to  the  precise  starting- 
point  of  bronchitis,  whether  in  the  connective  tissue  of 
the  bronchial  tubes,  or  in  other  structures,  some  question 
might  possibly  be  raised;  but  about  the  other  tissue- 
associations  of  gout  no  question  can  be  entertained.  The 
skeleton,  the  muscles,  the  vascular  system,  the  dermis, 
the  connective  tissue,  are  all  of  mesoblastic  origin.  In 
the  true  arthritic,  or  gouty  diathesis,  the  manifestations  of 
morbid  change  cling  to  those  outcomes  of  the  mesoblast. 
The  urinary  organs  have  the  same  origin  ;  and  stone  and 
gravel,  and  subsequent  kidney  changes,  were  recognised  as 


FIRST  STAGE. 


39 


outcomes  of  the  gouty  state.  Such,  indeed,  was  the 
gout  of  the  past.  It  manifested  a  decided  preference  for 
organs  of  mesoblastic  descent. 

But  there  is  a  general  tendency  at  the  present  time  to 
move  in  a  neurosal  direction.  Tempora  mutantur  nos  et 
mutamur  in  Mis.  The  massive  physique  of  the  Norseman 
is  gradually  passing  away,  and  a  lesser  being  of  higher 
nervous  development,  but  smaller  in  the  bone,  is  taking 
its  place.  This  is  well  seen  in  a  visit  to  Madame 
Tussaud's  Museum.  Contrast  the  living  crowd  of  small 
dark  beings  with  the  figures  of  a  by-past  time.  These 
latter  personages  have  a  large  skeleton,  big  muscles, 
light-coloured  eyes,  a  florid  complexion;  and  are  just  the 
persons  to  have  gout  in  their  extremities,  atheroma  in 
their  arteries,  and  ultimately  disease  in  their  aortic  valves; 
and  die  with  kidney  complications.  As  a  rule,  they  weigh 
about  one  half  more  than  the  living  beings  around  them. 
So  complete  is  the  transformation,  that  unless  a  country 
squire  happen  to  be  present  no  representative  of  the  past 
is  to  be  found  in  the  living.  In  the  country  the  old  type 
still  remains  as  a  survival ;  but  it  is  no  longer  to  be  found 
in  town-bred  people  as  a  rule. 

The  direction  is,  at  the  present  time,  distinctly  towards 
the  smaller  neurotic  or  Arab  type.  And  this  fact  is  the 
explanation  of  why  the  old-type  gout  is  less  commonly  seen 
now,  and  new  manifestations  are  coming  into  light.  It 
is  like  the  panoramic  scenes  of  dissolving  views  under  the 
magic  lantern.  One  is  passing  away  and  another  can  be 
seen  showing  through  it  ;  at  first  dimly,  then  more 
distinctly,  and  finally  in  clear  outline.  It  is  easy  to  note 
on  all  sides  this  change  going  on.  In  the  past  rustic 
youths  sought  adventure.     The  Norse  rover  gave  way  to 


4o  VASO-KENAL  CHANGE. 

the  knight-errant,  the  soldier  of  fortune ;  the  navigator 
who  sought  distant  and  unknown  seas.  Where  hard 
blows  were  to  be  met  with,  thither  went  the  adventurers. 
The  dangers  of  unexplored  seas  attracted  others.  Now 
we  find  a  very  different  state  of  affairs.  Men  engaged  in 
active  life  are  seeking  repose.  '  The  battle  of  modern 
life,'  as  Sir  J.  Crichton  Browne  says,  '  is  no  longer  fought 
with  thews  and  sinews,  but  by  the  nervous  system." 
We  educate  our  children  ;  in  the  struggle  for  existence  the 
brunt  of  the  battle  falls  upon  the  brain  as  '  the  organ  of 
mind.'  We  find  an  enormous  increase  of  maladies  of  the 
nervous  system.  It  is  not  in  the  rapid  growth  of  asylums 
for  the  insane  we  see  the  solitary  evidence  of  this  change 
at  the  present  time.  Indeed,  we  can  see  it  outside  man, 
in  the  increased  nervousness  of  the  modern  race-horse. 
It  cannot  bear  the  rough  usage — the  whip  and  spur — 
which  seemed  to  be  essential  of  yore  to  supreme  effort 
in  the  race.  A  horse  which  has  been  a  few  years  in 
London  will  remember  in  fear  a  cuff  in  the  face  which 
his  rustic  grandfather  would  scarcely  have  heeded ;  and 
taken  pretty  much  as  the  clown  who  inflicted  it  would  take 
a  cuff  from  his  milkmaid  Venus — rather  as  a  compliment 
than  otherwise. 

Town-life  has  a  decided  effect  in  reducing  the  thews 
and  sinews,  and  heightening  the  nervous  susceptibility. 
And  town  populations  now  exceed  rural  populations  in 
numbers.  We  have  now  a  larger  proportion  of  urban 
individuals  to  deal  with  ;  and  therefore  see  disease  in  new 
and  novel  forms.  Consequently,  we  will  not  be  surprised 
to  find  the  long  series  of  morbid  changes  which  spring 
from  liver-reversion  to  the  uric  acid  formation  undergoing 
modification.     It  is  not  the   products    of  the  mesoblast 


FIRST  STAGE.  41 

which  nowadays  are  being  mainly  involved.  We  find  the 
nervous  system  derived  from  the  epiblast  to  be  largely 
implicated.  Affections  of  the  epiblastic  epidermis  are 
common,  as  herpes  and  other  epidermal  skin  affections. 
The  glandular  elements  derived  from  the  hypoblast  are 
involved.  We  get  defective  secretion  from  the  gastric 
tubules ;  while  the  liver  is  liable  to  disturbances.  These 
react  on  the  nervous  system ;  and  we  get  bilious  head- 
aches and  migraine,  with  neurosal  disturbances  of  the 
heart.  The  epiblastic  and  hypoblastic  tissues  now  seem 
to  feel  mostly  the  weight  of  the  uric  acid  formation.  We 
are  seeing  a  new  phase  of  this  hepatic  reversion.  We 
had  gout  from  excessive  demand  upon  a  fairly  capable 
liver  till  it  gave  way  under  its  burden.  Now  we  see 
neurotic  personages,  whose  congenitally  insufficient  livers 
are  not  equal  to  dealing  with  even  ordinary  amounts  of 
food;  especially  animal  food.  There  seems  a  development 
of  the  nervous  system,  with  a  shrinking  of  the  viscera. 
In  this  latter  case  the  liver- reverts  to  the  uric  acid  forma- 
tion, just  as  much  as  in  the  former  case. 

The  Anglo-Saxon  in  the  United  States  of  America 
manifests  this  change  very  markedly.  He  is  almost  free 
from  the  gouty  maladies  of  the  Norseman.  But  the 
blood  of  Norseman  ancestors  runs  in  his  veins.  He  is  a 
neurotic  par  excellence.  Still  lithates  are  as  frequent 
(in  my  personal  experience)  in  the  modern  American 
lady  of  slight  physique,  with  a  highly-developed  nervous 
system,  a  feeble  liver,  and  small  digestive  capacity,  as  in 
the  burly  country  squire  of  England. 

Fordyce  Barker  says  that  the  people  in  the  United 
States  of  America  are  not  so  free  from  gout  as  is  often 
taken  for  granted.     It  is  there,  but  it  is  not  always  recog- 


A2  V A  SO-RENAL  CHANGE. 

nised.  Its  new  garb  is  to  a  certain  extent  a  disguise. 
But  now  that  that  disguise  is  penetrated,  the  matter  is  no 
longer  such  a  mystery.  The  uric  acid  formation  of  the 
functionally  feeble  liver  can  be  as  readily  recognised  in 
the  one  type  as  in  the  other,  when  the  liver  has  been 
over-burdened.  The  Norseman  country  squire,  and  the 
petite  neurosal  American  lady  of  limited  assimilative  power, 
equally  manifest  a  tendency  in  the  liver  to  descend  from 
the  urea  formation  to  the  urates  of  lowlier  creatures.* 

Clifford  Allbutt,  F.R.S.,  in  his  highly  interesting  work 
on  '  Visceral  Neuroses,'  has  pointed  out  how  commonly 
neurotics  have  a  family  history  of  gout.  It  is  not  in  the 
United  States  alone  that  this  divergence  from  the  old 
type  to  the  new — the  neurotic  direction — is  seen ;  it  is 
equally  seen,  if  not  to  a  like  extent,  amidst  the  popula- 
tion of  Yorkshire,  in  which  Dr.  Allbutt's  practice  mainly 
lies. 

•  After  these  considerations,  it  may  be  said  fairly  cor- 
rectly that  in  the  gout  of  the  Norseman,  chiefly  involving 
the  tissues  derived  from  the  mesoblast,  we  see  the  gout 
of  the  past — now  rapidly  disappearing ;  while  in  the  gout 
of  the  neurotic,  mainly  implicating  the  structures  derived 
from  the  epiblast  and  hypoblast,  we  recognise  the  gout  of 
the  future, — now  pretty  clearly  manifesting  itself. 

NORSE    TYPE. 

Vascular  Changes. — We  can  now  proceed  to  regard  the 
morbid  manifestations  of  the  vaso-renal  change  (with  its 
reversion   to    the    uric    acid   formation)  at   some   length ; 

8  Dr.  Lauder  Brunton,  F.R.S.,  has  recalled  to  my  mind  the  fact 
that  the  frog  has  a  fluid  urine  and  the  soluble  urea— a  sort  of  shadow 
thrown  forward  by  the  future  change. 


FIRST  STAGE.  43 

taking  the  slow  chronic  change  in  the  vascular  system, 
first. 

However  it  is  brought  about,  blood  charged  with  uric 
acid  does  set  up  a  certain  amount  of  spasm  in  the 
arterioles  of  like  character,  and  differing  only  in  degree 
from  the  spasm  of  the  angina  pectoris  vasomotoria  of 
Eulenberg.  The  clinical  fact  that  individuals  undergoing 
this  vaso-renal  change  are  those  persons  who  in  the  main 
manifest  angina,  falls  in  with  this  view,  and  corroborates 
it.  Angina  is  a  condition  of  acute  spasm,  superimposed 
upon  a  state  of  slighter  persisting  spasm.*  After  a  certain 
time  the  result  of  this  spasm  can  be  seen  in  a  distinct 
thickening  of  the  muscular  walls  of  the  arterioles.  That 
there  is  also  thickening  of  the  outer  coat  in  many  cases 
seems  certain.  As  these  coats  thicken  in  various  propor- 
tions, we  may  get  cases  of  muscular  hypertrophy ;  while 
in  others  the  change  might  more  correctly  be  spoken  of 
as  a  fibrosis ;  as  a  very  noticeable  discussion  before  the 
Medico-Chirurgical  Society  in  1870  and  1872  has  told  us. 
Whether  we  are  as  yet  in  a  position  to  speak  very 
definitely  about  arterial  changes,  may  be  called  in  ques- 
tion. One  thing  is  fairly  certain, — the  change  does 
obstruct  the  blood-flow  in  the  arterioles ;  with  the  conse- 
quence of  a  rise  in  the  blood-pressure  in  the  arterial 
system. 

This  change  is  well  seen  in  the  accompanying  engraving, 
which  is  a  section  of  a  renal  artery  taken  from  a  case  of 
early  cirrhotic  kidney.  It  illustrates  thickening  of  the 
muscular  coat ;  and  also  of  the  connective  tissue  of  the 

*  Dr.  Wm.  H.  Broadbent  thinks  that  sometimes  an  obstruction 
may  exist  in  the  capillaries,  raising  the  arterial  tension  without  arteriole 
spasm. 


44  VASO-RENAL  CHANGE. 

outer  coat — that   connective-tissue  growth  which  is  the 
great  anatomical  departure  in  the  vaso-renal  change. 

From  this  fairy  touch  upon  the  tiny  arterioles  follow 
many  and  grave  consequences.  But  at  the  commence- 
ment there  is  nothing  visible.  The  early  change  is  like  a 
comet  which  has  not  yet  come  within  the  sphere  of  our 
vision.  Perhaps  the  precise  moment  when  it  becomes 
visible  is  not  always  noted.  But  in  time  we  recognise  its 
existence  as  established.     The  result  is  a  full  artery ;  and 


i\n\ 


Fig.  3. — Section  of  Medium-sized  Artery  of  the  Kidney,  from  a  Case 
of  Interstitial  Nephritis. — The  middle  coat,  &,  is  thickened,  also  the 
tunica  adventitia,  a.     Magnified  200  diameters. 

with  that  the  energy,  both  muscular  and  mental,  of  a  free 
blood-supply.  For  years  the  individual  goes  on  the  type 
of  health,  very  often.  Others  again  are  liable  to  attacks 
of  rheumatism,  or  eczema,  or  bronchitis,  or  sciatica.  The 
first  stage  is  often  a  protracted  one ;  especialby  in  persons 
of  the  gouty  diathesis,  and  good  family  history.  But  in 
others  it  runs  its  course  with  more  rapidity,  and  brings  its 
victim  to  the  grave  before  the  middle  of  life  is  reached. 
But  the  hearty  fox-hunting  country  squire,  who  was  a 
stout  cricketer  and  football-player  in  early  days,  can  still 
carry  his  gun  over  turnips,  or  ride  to  hounds,  and  hold 
his  own  with  the  best  of  them.     The  full  artery  means  a 


FIRST  STAGE.  45 

liberal  supply  of  blood  to  all  organs  ;  and  vascularity  goes 
with  functional  capacity. 

The  full  artery  presents  an  obstacle  to  the  blood-flow 
out  of  the  left  ventricle  on  its  contraction,  and  this  leads 
to  hypertrophy  of  its  muscular  wall ;  by  virtue  of  that  law 
which  determines  hypertrophy  when  any  hindrance  exists 
to  the  ventricle  emptying  itself  completely ;  i.e.,  as  com- 
pletely as  it  normally  does.  (Leaving  over  some  considera- 
tions of  the  changes  in  the  left  ventricle  in  various 
individuals,  we  will  proceed  at  the  present  time  with  the 
usual  sequence  of  events.)  We  find,  then,  a  full  artery 
with  a  large  left  ventricle ;  and  from  the  high  arterial 
tension,  a  forcible  closure  of  the  aortic  valves  and  dis- 
tension of  the  aortic  root,  giving  us  a  loud  aortic  second 
sound.  A  tracing  taken  by  the  sphygmograph  at  this 
stage  will  show  the  square-headed  tracing  characteristic 
of  the  full  artery. 


Fig.  4. — Square-headed  Tracing. 

The  finger  feels  the  artery  full,  firm,  and  incompressible. 
The  sphygmograph  also  tells  of  this, — and  is  the  record  of 
what  the  finger  feels. 

As  a  curious  and  instructive  contribution  to  our  know- 
ledge of  this  change  may  be  mentioned  a  case  which  fell 
under  my  own  personal  observation.  A  man  of  thirty-five, 
who  had  had  severe  unmistakable  articular  gout,  but 
who  was  free  from  it  at  the  time,  was  staying,  ten  years 
ago,  at  a  large  country  house  where  the  fare  was  liberal,. 


46  VASO-RENAL  CHANGE. 

the  cellar  well  stocked,  and  the  company  good.  Without 
any  excess  in  food  or  drink,  he  certainly  was  overfed.  A 
distinguished  physiologist  was  one  of  the  guests  :  and 
one  day  he  took  pulse-tracings  of  the  company.  In  this 
particular  case  the  pulse-tracing  showed  the  characteristic 
and  well-recognised  square  head.  This  was  taken  as 
a  matter  of  course,  and  the  fact  created  no  surprise.  But 
half  a  dozen  years  later,  when  the  sphygmograph  was 
applied  to  the  same  artery,  the  peculiar  square  head  was 
a-wanting.  The  artery  furnished  a  perfectly  normal 
tracing.  Now  this  observation  harmonizes  with  the 
observations  of  Dr.  Broadbent  and  the  late  Dr.  Mahomed 
about  the  rise  of  arterial  tension  found  after  scarlatina 
when  the  blood  is  laden  with  waste  matter ;  and  which 
precedes  the  nephritis,  of  which,  however,  it  is  the  herald. 
This  has  a  most  distinct  bearing  upon  the  whole  question 
of  the  rise  in  arterial  tension,  and  the  changes  which 
•ensue  therefrom  when  the  blood  is  surcharged  with  waste 
matters.  The  fact  is,  indeed,  very  suggestive  in  several 
ways. 

The  condition  as  it  stands  at  this  stage  is  this — a  large 
left  ventricle  ;  a  loud  aortic  second  sound  ;  a  full  artery 
beginning  to  grow  harder  from  the  growth  of  connective 
tissue  in  its  wall ;  and  a  free  flow  of  urine — the  physio- 
logical evidence  of  high  arterial  tension.  Such  a  condi- 
tion in  a  man  of  good  family  history  will  be  maintained 
for  years,  and  often  many  years.  But  the  rate  of  progress 
is  by  no  means  the  same  in  all  cases.  It  varies  very 
considerably  from  a  scarcely  measurable  rate  in  some,  to 
a  course  of  a  few  years  in  others.  In  young  women  who 
pass  lithates,  it  is  comparatively  rapid  in  its  course ; 
certainly  more  rapid  in  an  urban  neurotic  than  a  rural 


FIRST  STAGE.  47 

Norseman.  A  number  of  such  cases  cross  my  field  of 
vision  as  I  write.* 

But  it  would  be  wrong  to  make  the  statement  that  pure 
concentric  hypertrophy  is  the  invariable  change  in  the 
left  ventricle.  The  first  step  is  incomplete  systole ;  and 
the  resultant  product  depends  (1)  upon  the  rate  at  which 
the  incomplete  contraction  is  set  up,  on  the  one  hand ; 
and  (2)  the  nutritive  powers  of  the  system  on  the  other. 
If  the  demand  be  from  a  torn  aortic  cusp,  then  hypertrophy 
will  be  diluted  by  dilatation  from  the  suddenness  of  the 
demand  ;  even  when  the  nutrition  is  good.  Where  the 
demand  is  slow,  as  is  usual  in  vaso-renal  change,  the  dila- 
tation is  arrested  by  hypertrophic  growth  before  it  is 
measurable ;  and  pure  concentric  hypertrophy  is  the  re- 
sult. But  this  involves  good  nutrition  ;  and  the  nutrition 
in  a  gouty  man  of  the  Norse  type  is  usually  good,  and  the 
complexion  high.  Where  the  nutrition  is  not  good,  then  the 
hypertrophy  is  found  with  some  dilatation.  In  women 
the  nutrition  is  inferior  to  man  ;  and  the  vaso-renal 
change  with  women  is  often  found  with  imperfect  hyper- 
trophy, viz.,  a  condition  of  hypertrophy  blended  with  dila- 
tation. 

During  this  time  there  is,  in  the  bulk  of  cases,  little  or 
no  evidence  of  the  change  affecting  the  kidney ;  though 
this  varies  in  different  individuals.  In  some  there  exists  a 
more  pronounced  tendency  for  the  kidney  to  suffer  than 
is  the  case  with  others.  In  these  last,  evidences  of  renal 
injury,  such  as  albuminuria  and  tube-casts,  or  the  presence 
of  lithates,  are  furnished  ;  while  in  many  any  silent  change 
going  on  in  the  kidneys  makes  no  sign.     The   urine  is 

*  It  is  obvious  that  in  all  cases  the  progress  will  be  slower  if  the 
uric  acid  formation  be  lessenecPby  a  proper  dietary  and  regimen. 


48  VA SO-RENAL  CHANGE. 

clear,  copious,  but  otherwise  natural.  Possibly  it  is  dis- 
tinctly acid.  Also,  there  is  a  tendency  to  get  up  in  the 
small  hours  of  the  morning  to  empty  the  bladder.*  Some 
exposure  to  cold  may  lead  to  some  tubular  nephritis ;  and 
then  '  Bright's  Disease  '  is  added  to  the  vaso-renal  change, 
blending  with  it,  and  altering  its  hue  and  complexion  ; 
while  in  other  cases  some  renal  trouble  may  be  the  first 
departure  from  health.  But  speaking  broadly,  probably 
the  bulk  of  cases  fall  under  Dr.  Mahomed's  category  of 
'  Chronic  Bright's  Disease  without  albuminuria,'  i.e.,  the 
albumen,  if  present  at  all,  is  only  found  fitfully,  and  in 
comparatively  insignificant  quantities. 

Articular  Gout. — Cheiragra  and  podagra  were  produced 
by  deposits  of  urate  of  soda  in  the  articular  cartilages  of 
the  small  bones  of  the  extremities.  Of  course  a  certain 
amount  of  deposit  must  be  accumulated  before  the  change 
in  form  is  obvious.  Dr.  Garrod,  in  his  work  on  '  Gout/ 
shows  a  portion  of  synovial  membrane  from  the  knee, 
where  the  little  specks  of  uric  acid  can  be  seen  of  the  size 
of  a  small  pin's  head,  when  magnified  60  diameters.  He 
also  shows  cases  where,  after  one  slight  attack  of  gout, 
minute  naked-eye  deposits  of  urate  of  soda  can  be  seen. 
Also  minute  deposits  from  the  cartilage  of  the  left  great 
toe,  which  had  never  suffered  ;  and  the  actual  gout  was 
confined  to  the  right  great  toe.  Though  the  ball  of  the 
great  toe  is  the  home  par  excellence  of  gout,  it  has  other 
favourite  habitats,  as  the  knuckles  for  instance.     The  fore 

0  The  country  squire  in  this  condition  usually,  when  up,  looks  out 
to  see  what  the  weather  is  like.  This  may  arise  from  agricultural 
interests,  or  he  is  a  hunting-man,  or  a  game-preserver;  but  his  game- 
keepers always  believe  he  gets  up  to  look  out  in  order  to  cross-examine 
them  about  the  weather  ;  to  see  if  they  were  out  and  about  in  the  night 
doing  their  duty. 


FIRST  STAGE.  49 

and  middle  lingers  are  the  common  seat  of  gouty  deposits 
in  the  knuckles — the  metacarpal  ends  of  the  phalanges. 
The  proximal  end  of  the  thumb  is  less  frequently  its  seat. 
Small  nodosities  may  be  felt  along  the  fingers,  sometimes 
seated  in  the  sheaths  of  the  tendons.  The  knee  is  most 
frequently  affected  as  regards  the  large  joints,  and  is  also 
liable  to  synovial  effusion.  Both  ends  of  the  humerus 
may  be  encrusted,  and  so  may  either  end  of  the  femur. 
Gout  in  the  wrist  is  rare,  but  very  painful.  Gouty  pain  is 
also  felt  on  the  instep  and  in  the  heel  (very  characteristic) ; 
and  at  the  insertion  of  the  tendo  Achillis,  and  also  in  the 
aponeurosis  of  the  gastrocnemius.  Charcot  has  found 
gouty  infiltration  in  the  sheaths  of  nerves ;  and  certainly 
sciatica  is  common  with  gouty  persons  of  the  Norse  type. 
Dr.  Garrod  states  '  that  extensive  deposits  may  take  place 
within  the  joints  without  Corresponding  external  manifes- 
tation ;'  and  there  seem  good  grounds  for  believing  that 
in  many  of  these  cases,  where  pain  is  experienced  without 
change  of  form,  there  is  some  deposit,  but  not  enough  to 
cause  visible  change  of  form.  He  continues,  '  I  am  of 
opinion  that  not  only  is  the  deposition  of  urate  of  so.da 
constantly  found  in  gouty  inflammation,  but  that  it  stands 
to  it  in  the  relation  of  cause  rather  than  effect ;  that  is  to 
say,  the  deposition  of  the  salt  first  takes  place  in  the 
synovial  membranes,  cartilages,  and  tendinous  structures 
of  the  joint,  and  by  its  presence  gives  rise  to  inflammatory 
action.' 

Repeated  attacks  of  gout,  i.e.,  acute  gouty  inflammation 
in  the  joint,  tend  to  prevent  enlargement  by  further  depo- 
sition, to  a  greater  or  less  extent.  The  late  Bence  Jones 
thought  that  such  inflammation,  by  raising  the  tempera- 
ture of  the  part,  exercised  an  oxidizing  influence  over  the 

4 


5° 


V A  SO-RENAL  CHANGE. 


urates  ;  while  this  rise  of  temperature  tends  to  render  the 
urates  soluble,  and  so  once  more  to  enter  the  blood- 
current,  and  to  find  their  way  out  of  the  system.  The  in- 
flammation is  not  the  disease,  but  its  consequence,  '  the 
thunder-storm  which  clears  the  air ;'  and  consequently 
Mead  said,  '  Gout  is  the  cure  of  gout.' 

One  remarkable  fact  about  gouty  inflammation  is  this — 
the  comparative  rarity  of  suppuration.  As  a  broad  rule, 
suppuration  does  not  occur,  but  occasionally  abscesses 
do  form  ;  and  the  presence  of  pus  does  not  positively 
forbid  a  gouty  element  in  the  case, — though  it  casts  a 
doubt  upon  it. 


33Kfo. 


A 


B 


Fig.  5. — A.  Crystals  of  Urate  of  Soda  deposited  in  the  Articular 
Cartilage  (after  Cornil  and  Ranvier).  It  will  be  noticed  that  the 
deposit  has  occurred  more  particularly  in  the  cartilage  cells,  especially 
near  the  joint  surface.  Magnification,  300  diameters.  B  is  the  micro- 
scopic appearance  of  the  deposited  crystals  within  the  cartilages, 
after  Garrod.     1.  30  diameters.     2.  A  point  of  220  diameters. 


Another  remarkable  fact  about  gouty  deposits  on  a  large 
scale  in  the  hands  and  feet,  is  that  where  these  are  very 
conspicuous  the  general  health  keeps  good  ;  and  these 
persons  usually  are  little  plagued  with  gout  in  other  forms 


FIRST  STAGE.  51 

— at  least  until  the  end  is  approached.  In  one  case,  a 
foreman  painter,  his  hands  and  feet  were  woefully  de- 
formed ;  but  his  chief  complaint  was  of  a  large  deposit 
over  the  middle  phalanx  of  his  right  ring-finger,  which 
was  constantly  getting  in  the  way,  and  being  knocked. 

A  tiny  deposit  on  the  articular  cartilage,  telling  that  the 
urate  of  soda  has  made  its  initial  invasion,  is  shown  in 
the  accompanying  drawing. 

Sometimes  the  latent  deposit  gives  no  sign  of  its  pre- 
sence (unless  it  be  occasional  twinges  of  pain)  until  some 
injur)r  to  the  joint  is  experienced,  whereupon  gouty  in- 
flammation sets  in,  and  with  considerable  severity  in  some 
cases. 

Rheumatism. — Gouty  persons  of  the  Norse  type  are  de- 
cidedly subject  to  rheumatism,  especially  of  the  shoulder 
and  upper  arms.  Sometimes  it  seems  truly  muscular, 
and  confined  to  the  muscles  or  their  aponeuroses.  At 
other  times  it  has  periosteal  relations ;  and  adhesions  form 
which  require  to  be  broken  down  before  relief  from  pain 
or  freedom  of  movement  can  be  attained.  The  arm 
becomes  locked  by  them,  and  spontaneous  movement  is 
abolished.  It  is  in  these  cases  that  passive  movement 
and  massage  are  so  successful. 

Lumbago  is  certainly  frequent  in  such  persons ;  and  so 
is  '  cramp.' 

Exposure  to  cold  will  bring  on  an  attack  of  rheumatism 
in  persons  predisposed  to  it ;  but  how  is  it,  it  may  be 
asked,  that  rheumatism  is  produced  by  exposure  at  one 
time,  when  like  exposure  for  a  score  of  times  leads  to  no 
such  result  ?  There  must  be  some  modifying  factor ;  and 
from  my  experience  as  a  general  practitioner  in  the  North 
of  England,  where  rheumatism  is  very  frequent,  as  well  as 

4—2 


52  VASO-RENAL  CHANGE. 

from  country  patients  seen  now,  it  has  seemed  to  me  that 
the  factor  is  the  proportion  of  urate  in  the  blood.  At  any 
rate,  these  rheumatic  persons  are  liable  to  find  red  lithates 
pretty  constantly  in  their  urine.  The  efficacy  of  the  pill 
consisting  of  mercury,  ipecacuan,  and  colchicum,  given  by 
the  late  Dr.  Fuller  in  his  work  on  '  Rheumatism  and 
Rheumatic  Gout,'  is  certainly  another  piece  of  evidence 
in  favour  of  this  hypothesis.  Another  is  the  great  utility 
of  potash  in  rheumatism.  If  anyone  will  take  the  trouble 
to  compare  Dr.  Garrod's  work  on  Gout  (representing  the 
views  of  the  present  day),  with  that  of  the  late  Sir  Charles 
Scudamore  (representing  the  views  entertained  half  a 
century  earlier),  he  will  see  for  himself  how  many  mala- 
dies have  passed  over  from  the  class  'rheumatism'  to 
'  gout.'  My  own  opinion  leans  to  the  view  that  '  rheu- 
matism,' of  chronic  or  subacute  character,  is  one  of  the 
manifestations  of  the  uric  acid  formation — one  of  its 
Protean  forms,  indeed ;  whatever  acute  rheumatism  may 
depend  upon  casually. 

Many  persons  will  admit  that  their  trouble  is  '  rheu- 
matic,' who  disdain  the  term  '  gouty '  as  applicable  to 
them  or  their  maladies.  '  A  rose  by  any  other  name  will 
smell  as  sweet.'  As  a  gouty  man  of  Norse  type,  the 
writer  knows  from  personal  experience  perfectly  well  the 
pain  of  acute  articular  gout,  and  the  sudden,  sharp,  gouty 
twinge  in  the  heel,  or  elsewhere ;  and  the  dull  pain  of 
muscular  rheumatism.  Of  persistent  pain  he  has  had  no 
experience ;  but  its  features  are  quite  distinct,  and  it  is- 
easily  diagnosed.  That  the  pain  of  the  uric  acid  forma- 
tion should  differ  according  to  the  tissue  affected,  is  no 
more  than  reason  would  tell  us  to  expect. 

Chronic    Bronchitis. — The   relation    of    bronchitis,    and. 


FIRST  STAGE.  53 

specially  if  recurrent,  with  the  uric  acid  formation  is  now 
widely  recognised.  Sir  Henry  Holland  observed  it ;  and 
Dr.  Headlam  Greenlow  placed  the  matter  beyond  dis- 
pute. It  may  alternate  with  articular  gout,  or  eczema,  or 
psoriasis.  He  says,  '  I  well  recollect  a  striking  example 
of  this  alternation  in  the  case  of  an  elderly  man  who  was 
long  under  my  care.  His  ailments  were  gout,  psoriasis 
and  bronchitis,  and  he  was  rarely  or  never  free  from  all 
of  them.  No  two  of  the  three  ailments  ever  co-existed  in 
his  case  ;  but  it  would  happen  that  just  as  he  was  con- 
gratulating himself  on  having  got  rid  of  the  gout,  his  skin 
would  become  covered  with  psoriasis,  and  that  in  a  few 
weeks  would  take  its  departure,  and  be  succeeded  by  an 
attack  of  bronchitis.'  Such  alterations  point  to  some- 
thing causal  and  common  to  all  the  maladies. 

'  My  personal  acquaintance  with  the  matter  arose  from 
my  testing  the  acidity  of  the  sputum  as  an  indication  for 
the  exhibition  of  alkalies  in  the  treatment  of  chronic 
bronchitis  in  my  early  days.  When  the  scene  of  my 
labours  passed  from  the  Westmoreland  hills  to  the  Leeds 
Public  Dispensary,  I  found  a  number  of  cases  of  chronic 
bronchitis — especially  during  the  winter  months — in  stal- 
wart individuals,  which  did  not  do  well  on  the  routine 
cough  mixtures  of  the  institution.  Very  frequently  there 
was  co-existent  dyspepsia,  or  some  skin  affection.  A 
suspicious  family  resemblance  pervaded  them ;  and  in 
substituting  a  mixture  containing  potash  for  the  ordinary 
cough  mixture,  the  improvement,  so  inaugurated,  strength- 
ened the  suspicion  into  a  conviction  '  ('  Chronic  Bron- 
chitis ;  its  Forms  and  their  Treatment  '). 

Further  experience  has  corroborated  the  conclusions 
thus  formed ;   and   the    chronic   bronchitic    is    usually  a 


:54  VASO-RENAL  CHANGE. 

person  furnishing  plenteous  testimony  elsewhere  of  the 
existence  of  this  vaso-renal  change. 

Emphysema. — Of  course  where  there  is  much  cough 
there  is  emphysema.  After  an  attack  of  acute  bronchitis 
in  the  young,  a  certain  amount  of  distension  of  the  air 
vesicles  is  constantly  found.  But  with  the  elasticity  of 
the  lung-tissue,  this  more  or  less  perfectly  disappears  ;  as 
does  the  emphysema  of  the  ambitious  young  athletes. 
But  as  years  advance  the  lung  loses  this  readiness  to 
reduce  the  emphysema,  and  each  attack  of  bronchitis 
leaves  the  condition  aggravated.  The  congestion  of  the 
venous  system,  and  especially  the  valveless  portal  cir- 
culation, which  is  the  result  of  impeded  blood-flow  in  the 
lungs,  is  markedly  seen  in  the  liver ;  and  its  functions  are 
further  impaired.  Not  only  that,  but  the  liver  is  dis- 
placed downwards  with  the  flattening  diaphragm.  This 
matter  has  been  recognised  as  a  clinical  fact ;  but  its 
recognition  ought  to  lead  to  thought,  inspiring  a  thera- 
peutic direction.  The  liver  occupies  the  warmest  and 
cosiest  nook  of  the  body,  well  sheltered  from  cold.  But 
when  displaced  downwards  beyond  the  edge  of  the  ribs, 
a  portion  of  it  is  covered  merely  by  the  abdominal 
parietes,  and  so  is  readily  chilled.  '  A  bilious  chill '  is 
commonly  something  more  than  a  mere  fashionable  ex- 
pression. When  so  displaced  the  exposed  liver  ought  to 
be  covered  over  carefully  by  a  stout  belt  of  flannel,  or  a 
cummerbund. 

Eczema. — The  skin  of  persons  undergoing  vaso-renal 
change  with  the  uric  acid  formation  is  frequently  affected. 
The  most  common  and  serious  of  these  cutaneous  mala- 
dies is  eczema.  Frequently  this  is  the  main  ailment, 
especially  when  severe ;  and  a  very  serious  matter  it  may 


FIRST  STAGE.  55 

be.  The  lower  limbs  seem  specially  liable  to  form  its 
seat.  It  is  common  in  the  person  of  Norse  type,  and  com- 
mences in  the  true  dermis  of  the  mesoblast.  It  is  an 
inflammation  of  the  corium  beneath  the  epidermis.  In 
some  persons  of  this  class,  it  gives  rise  to  the  most  intense 
itching,  or  to  stinging  pain.  Some  authorities  say  they 
have  not  remarked  these  two  associates  in  skin  affections 
in  gouty  persons  ;  while  others  assert  that  gouty  eczema 
carries  with  it  an  intensity  of  pain  and  itching. 

Psoriasis  palmaris  is  frequent  in  young  men  who  are  the 
heirs  of  gout.  Pruritus  certainly  is  common,  as  pruritus 
vulva?  in  one  sex,  and  pruritus  ani  in  both.  The  first  is 
probably  due  to  the  irritant  properties  of  the  urine ;  * 
while  the  latter  is  due  to  congestion  of  the  portal  circu- 
lation, working  backward  from  some  impediment  to  the 
blood-flow  in  the  liver. 

Secondary  Valvular  Disease  of  the  Heart. — Earlier  in  this 
chapter  the  rise  in  arterial  tension  in  vaso-renal  change 
was  described.  It  was  seen  how  this  usually  led  to  hyper- 
trophy of  the  left  ventricle  to  overcome  the  resistance 
offered  to  the  outflow  of  blood  from  the  heart  on  systole. 
It  was  pointed  out  how  the  violent  closure  of  the  aortic 
valves  produces  a  distinct  modification  of  the  aortic  second 
sound,  heightening  and  accentuating  it  ;  just  as  the  pul- 
monary second  sound  becomes  louder  and  clearer  when 
there  is  obstruction  offered  to  the  blood-flow  in  the  pul- 
monary circulation — whether  this  be  due  to  changes  in 
the  lungs,  or  to  mitral  disease.  Under  such  circumstances 
we  find  enlargement  in  the  right  ventricle,  and  loud  pul- 
monary second  sound,  with  atheromatous  change  in  the 
pulmonary  artery. 

*  Often  containing  some  sugar. 


56  W4SC-RENAL  CHANGE. 

The  strain  thus  put  upon  the  aortic  valves  in  a  number 
.of  cases  leads  to  valvulitis.  There  is  a  premurmuric  stage 
by  which  the  possibility  of  coming  valvulitis  can  be  con- 
jectured ;  and  in  a  certain  proportion  of  cases  the  tell-tale 
:murmur  puts  in  its  appearance  in  a  measurable  time.  I 
do  not  know  that  we  can,  as  yet,  discriminate  betwixt  those 
cases  where  the  accentuated  aortic  second  sound  will  go 
on  and  on  without  any  evidence  of  valvulitis,  from  those 
where  the  valvulitis  follows  at  no  great  interval  of  time. 
But,  sure  enough,  in  a  certain  proportion  there  is  ere  long 
evidence  of  valvular  mischief  on  foot.  This  form  con- 
stitutes the  sclerosing,  or  progressive  variety  ;  contrasting 
with  the  static  injury  of  primary  valvulitis.*  It  goes  from 
bad  to  worse  ;  and  in  some  cases  but  a  few  years  elapse 
before  the  end  is  nigh.  The  strain  upon  the  valve-curtains 
is  such  that  the  disease  once  started  progresses.  In  three 
or  four  years  the  course  is  run  in  some  cases ;  while  in 
one  case  known  to  me,  eight  years  have  elapsed  without 
any  measurable  progress  having  been  made.  We  do  not 
yet  have  sufficient  data  to  determine  the  course  of  aortic 
valvulitis,  which  is  secondary  to  and  causally  related  to  a 
large  left  ventricle  in  vaso-renal  change.  It  is,  however, 
the  progressive  form  found  with  persons  advanced  in 
years.  But  it  is  not  confined  to  persons  getting  on  in 
life.  After  forty  it  is  found  increasing  and  gathering  as 
years  roll  on. 

In  one  case,  well  known  to  me,  aortic  valvulitis  was  the 

*  The  two  forms  of  valvulitis  were  well  shown  in  the  case  of  the 
late  Lord  Iddesleigh.  He  had  a  mitral  valvulitis  in  early  life,  follow- 
ing rheumatic  fever.  For  years,  in  accordance  with  the  medical  views 
of  that  time,  he  abstained  from  public  life,  but  subsequently  entered 
it  without  injury.  Later  on  in  life  aortic  valvulitis  set  in  with  a  gouty 
heart ;  and  this,  in  a  few  years,  brought  life  to  a  close. 


FIRST  STAGE.  57 

first  recognised  manifestation  of  gout.  The  patient,  a 
medical  man,  had  acid  dyspepsia,  flatulence,  and  a  con- 
siderable output  of  lithates.  Being  in  the  habit  of  having 
a  stethoscope  applied  to  his  chest,  more  in  joke  than  in 
earnest,  when  in  my  consulting-room,  one  day,  to  my 
horror,  I  found  a  distinct  regurgitant  murmur  at  the 
aortic  valves.  This  valvulitis  was  treated  just  as  a 
primary  attack  of  gout  in  the  great  toes  would  be.  All 
exertion  was  forbidden,  the  arterial  tension  was  kept 
down  by  a  rigid  dietary,  and  sweeping  all  waste  matters 
out  of  the  blood.  He  took  an  intelligent  view  of  his  own 
case,  saw  the  advantages  to  be  derived  from  rational 
treatment,  and  got  his  reward.  The  case  has  Come  to  a 
standstill,  at  least  so  far  as  human  eye  can  see,  having 
been  under  observation  four  years.  He  leads  as. quiet  a 
life  as  is  possible  to  him ;  and  permits  no  accumulation  of 
nitrogenized  waste  in  his  blood. 

But  it  is  not  only  in  the  aortic  valve  we  see  this 
secondary  inflammation  from  strain  on  the  valve-curtains 
with  a  hypertrophied  left  ventricle.  The  strain  upon  the 
mitral  valve-curtains  can  often  be  learned  by  the  loud 
sound  of  their  forcible  closure.  Sometimes  insufficiency 
is  the  result ;  sometimes  fusion  of  the  free  edges  together 
(producing  stenosis)  is  the  result.  Sometimes  the  case 
goes  on  measurably  from  bad  to  worse  ;  but  an  extending 
experience  tells  me  that  this  is  not  invariably  the  case. 
The  larger  the  left  ventricle  and  the  greater  the  strain  the 
more  rapid  the  progress.  It  is  in  such  cases  that  acute 
bronchitis  is  so  apt  to  be  fatal  in  persons  not  expected  to 
succumb.  When  there  is  such  stenosis  with  general 
enfeeblement  of  the  system,  the  progress  is  decidedly 
slow. 


58  V A  SO-RENAL  CHANGE. 

THE    NEUROTIC    OR    ARAB    TYPE. 

Having  considered  the  direction  taken  by  vaso-renal 
change  with  the  uric  acid  formation,  in  the  Norse  type — 
the  extreme  right — it  is  now  time  to  consider  its  career 
and  course  in  the  neurotic — the  extreme  left;  recognising 
and  not  forgetting  intermediate  forms,  blends,  or  hybrids. 
In  order  to  more  properly  comprehend  the  increase  in  the 
neurotic  class  at  the  present  day,  a  short  historical 
digression  is  desirable.  An  historical  digression  in  a 
pathological  essay  may  seem  to  some  out  of  place. 
Homo  sum,  et  nihil  humani  a  me  alienum  puto.  A  medical 
man  ought  to  know  something  of  the  individual  in  whom 
disease  exists,  as  well  as  be  familiar  with  the  disease.  I 
shall,  therefore,  make  no  apology  for  such  digression;  but 
just  leave  it  to  vindicate  itself. 

When  the  Teutonic  eruption  took  place  we  find  a  large 
massive  race  of  strong  bones  and  huge  muscles  ;  a  hard 
worker,  a  harder  fighter — fond  of  combat  with  man  or 
beast,  and  of  high  physical  courage  ;  subduing  by  sheer 
physical  prowess  the  slighter  Celto-Iberian  races  of 
Western  Europe:  while  his  wife  was  the  robust  mother  of 
stalwart  sons.  These  Norsemen  became  the  dominant, 
or  aristocratic  class  of  the  conquered  countries.  The 
'  holy  Child '  of  the  early  Spanish  painters  is  evidently  of 
Visigoth  parentage.  The  '  Madonna  '  of  the  Italian 
painters  is  clearly  of  Teuton  descent.  Circumstances  at 
that  age  favoured  the  man  of  stalwart  physique — the  work 
of  the  field  and  forest ;  the  rough  sports  and  games  in 
which  physical  strength  was  a  great  advantage  and  gave 
pre-eminence.  In  the  personal  combat  and  the  hand-to- 
hand  fight  of  war  the  same  was  found  ;  and  still  more  the 


FIRST  STAGE.  59 

use  of  the  mighty  war-bow — to  string  and  draw  which 
stature  was  essential — favoured  the  stalwart  Norse- 
man ;  who  was  also  fond  of  animal  food  and  a  hard 
drinker.  It  was  in  these  persons,  or  individuals  de- 
scended from  them,  that  gout  was  seen  and  studied. 

But  as  time  went  on  these  specially  favoured  persons 
lost  many  of  their  advantages.  First  came  the  walled 
town  in  which  the  slight  man  could  live  safely  as  a  skilled 
handicraftsman,  producing  inlaid  armour  and  weapons  of 
war.  Then  came  the  introduction  of  gunpowder,  which 
substituted  the  cannon  and  the  small  arm  for  the  bow  ; 
and  the  big  man  was  shorn  of  much  of  his  advantage  over 
the  little  man  in  warfare.  Later  still  came  the  introduc- 
tion of  the  steam-engine,  which  did  away  largely  with  the 
necessity  for  physical  strength  in  men.  The  small  man  of 
acute  brain  is  now  in  demand  in  skilled  manufacture  and 
the  tending  of  machinery.  The  late  John  Richard  Green, 
the  historian,  held  that  the  descendants  of  the  old 
Cymri  were  rolling  back  the  incursion  of  the  Anglo-Saxon 
who  drove  their  ancestors  into  mountain  fastnesses.  And 
it  would  seem  that  he  is  right,  and  that  the  prophecies 
of  Merlin  are  at  last  to  be  realized.  The  growth  of 
education  has  done  much  to  favour  the  small  neurotic. 
The  man  who  was  too  puny  to  fight  in  the  rough  old 
days  is  now  in  demand  as  a  clerk  and  a  teacher,  as  well 
as  a  mill  hand,  or  a  skilled  artisan.  Then  as  culture 
went  on,  we  must  not  overlook  the  increasing  attractive- 
ness of  the  bright-brained  neurotic  woman. 

The  whole  tendency  of  modern  progress  has  favoured 
the  growth  of  the  neurotic,  and  decreased  the  advantages 
which  of  old  gave  the  Norse  type  the  upper  hand.  We 
see  the  change  going  on  apace  on  all  sides.     The  inhabi- 


60  VA SO-RENAL  CHANGE. 

tants  of  English-speaking  America  are  distinctly  moving  in 
the  neurotic  direction  ;  and  so  are  the  Australians.  And 
as  time  goes  on  the  neurotic  will  apparently  kill  out  the 
Norse  type ;  who  can  already  be  seen  distinctly  to  be 
dying  out  as  regards  the  '  statesmen  '  of  the  sister  counties 
of  Cumberland  and  Westmoreland.  The  old  type  is  dying 
out,  and  a  slighter  race  is  taking  their  place  (see  p.  41); 
But  of  course  it  is  not  in  rural  and  agricultural  districts 
where  the  change  of  type  is  so  pronounced.  It  is  in  our 
urban  population  that  we  see  the  change  so  marked  and 
extensive.  When  I  left  the  North  of  England  for  the 
Metropolis,  I  encountered  a  new  race  in  the  out-patient 
room.  Instead  of  the  stalwart  fair  Saxon  or  red-haired 
Dane,  was  to  be  seen  a  small  dark  race  of  high  nervous 
susceptibility.  The  experience  among  the  Norse  type 
had  to  be  tempered  and  modified  to  meet  the  wants  of 
the  neurotic. 

With  such  a  widespread  change  of  type  going  on,  we 
can  feel  no  surprise  at  a  long  chronic  pathological  process 
being  modified  and  running  a  different  course  in  the  Norse 
type  and  the  neurotic  Arab  :  and  that  the  aspect  assumed 
by  it  in  the  one  is  widely  different  in  features  from  its 
aspect  in  the  other.  Hitherto,  the  uric  acid  formation 
has  been  studied  in  the  large  frame  of  the  Norse  type ; 
where  competent  digestive  organs  have  been  over-taxed 
by  indulgence  of  the  palate,  giving  us  the  '  rich  man's 
gout.'  Now  we  are  learning  to  recognise  the  reversion 
of  the  liver  to  the  uric  acid  formation  in  persons  of  the 
neurotic  type  with  congenitally  small  viscera,  '  the  poor 
man's  gout.'  It  is  not  an  accident,  nor  yet  caprice,  which 
is  guiding  the  populace  at  the  present  day  towards  tee- 
totalism  and  vegetarianism.      There  is   something  lying 


FIRST  STAGE.  61 

deeper  than  the  will.  What  forms  the  will,  and  guides 
the  choice  ?  A  profound  change  of  type,  as  seen  above. 
The  beef  and  ale  of  the  past  are  forbidden  to  the  neurotic 
by  a  law  which  he  instinctively  obeys  in  blind  submission. 

This  digression  is  a  matter  which  I  respectfully  submit 
to  the  physicians  of  North  America,  and  of  Australasia. 
The  change  of  type  will  explain — at  least,  so  it  seems  to 
me — the  modifications  in  food  -  customs  found  among 
them  ;  the  decline  in  alcoholic  drinks ;  the  advance  in 
such  stimulants  as  tea  and  coffee ;  the  resort  to  tonic 
medicines,  as  compared  to  the  lowering  treatment  of  the 
past.  It  certainly  has  a  good  deal  to  do  with  the  brain- 
overwork  of  which  we  see  so  much  at  the  present  time ; 
and  equally  certainly  it  plays  a  large  part  in  the  diminished 
energies  of  the  digestive  organs ;  which  seems — by  some 
curious  law — to  go  hand  in  hand  with  the  high  nervous 
development.  Why  the  expansion  of  the  nervous  system 
of  the  epiblast  should  be  accompanied  by  a  shrinkage  in 
the  organs  derived  from  the  hypoblast,  is  not  apparent. 
But  the  fact  remains — Magna  est  Veritas. 

We  must  first  see  a  thing  before  we  can  explain  what 
it  is,  and  how  it  comes  about.  As  the  neurotic  becomes 
the  great  majority  of  the  population,  we  can  feel  no  sur- 
prise in  the  increase  of  nervous  affections  of  all  kinds  at 
the  present  time ;  and  that  in  this  widespread  change  of 
type,  new  affections  linked  with  the  nervous  system  are 
coming  within  the  range  of  our  vision — certainly  they  are: 
Of  that  well-marked  disease,  '  the  General  Paralysis  of 
the  Insane,'  with  all  its  characteristic  features,  we  have 
no  account  till  the  present  century;  and  yet  now  it  is  a 
very  common  malady  indeed  in  our  asylums.  But  it  does 
not  stand  alone  in  this  respect  of  recent  birth.     Many 


62  V  A  SO-RENAL  CHANGE. 

maladies  are  of  modern  origin.  Nervous  disorders  of  the 
heart  were  first  distinctly  written  upon  by  B.  W.  Richard- 
son, F.R.S.,  who  is  not  yet  an  old  man ;  and  already  they 
form  a  well-recognised  class  of  maladies. 

It  would  seem  that  there  is  a  disturbance  of  balance  at 
the  present  day  betwixt  the  nervous  system  in  its  demands, 
and  the  supply  of  pabulum  furnished  by  the  digestive 
organs.  The  systematic  over-demand  upon  the  brain 
leads  to  exhaustion,  because  the  assimilative  organs  can- 
not supply  material  to  the  brain  in  a  sufficient  quantity ; 
while  brain-overwork  certainly  impairs  the  efficiency  of 
the  liver.  What  the  father  acquires  the  children  inherit — 
in  other  matters  than  worldly  goods.  The  hard  brain- 
worker  produces  a  child  with  a  highly-developed  nervous 
system :  but  with  defective  assimilative  organs.  There  is 
the  movement  in  the  macrocosm,  and  the  movement  in 
the  microcosm  ;  and  there  seems  every  reason  to  fear  that 
the  next  generation  of  the  North  Americans,  especially  as 
regards  the  town-populations,  will  manifest  the  neurotic 
type  and  characteristics  even  more  markedly,  and  to  a 
larger  extent,  than  the  present  generation.  The  uric  acid 
reversion  may  not  always  be  a  long-drawn  inheritance 
from  gouty  ancestry  stretching  far  away  back ;  but  may 
have  a  much  shorter  pedigree.  It  may  possibly  date  back 
little  more  than  a  generation.  An  energetic  man  may 
build  up  a  fortune ;  and  with  it  his  neurotic  daughter 
inherits  small  digestive  capacity,  and  a  marked  tendency 
to  the  uric  acid  formation — at  least  so  it  appears  to  me 
from  the  opportunities  I  have  had  of  observing  patients 
from  the  United  States  of  America.  It  is  not,  however, 
confined  to  the  daughters ;  there  are  men  of  the  same 
type.     Nor  is  this  type  confined  to  the  Western  Hemi- 


FIRST  STAGE.  63 

sphere  ;  the  neurotic  is  found  in  Yorkshire.  This  is  Clifford 
Allbutt's  sketch  :  '  The  limbs  are  small,  but  often  very 
sinewy.  Such  persons  are  as  active  as  birds,  and  the 
absence  of  fat  in  their  muscles  often  gives  to  these,  in 
states  of  health,  the  quality  of  hardness  under  the  hand. 
Their  conversation,  again,  is  lively,  voluble,  often  keen 
and  brilliant,  but  impressionable  rather  than  imaginative  ; 
you  may  generally  notice  in  them,  too,  some  little  blink- 
ing, twitching,  or  tattooing,  which  quickens  as  words  and 
thoughts  flow  faster.  Usually,  such  a  patient  does  not 
readily  come  to  you  ;  he  is  brought,  half-reluctant,  by  his 
wife  or  friends.  He  says,  apologetically,  he  is  an  old 
dyspeptic,  and  you  can  do  him  no  good.  He  has  visited 
all  the  springs  and  half  the  doctors  in  Europe,  and  lays  a 
bundle  of  old  prescriptions  on  your  desk.  Once  a-gate, 
however,  his  story  will  be  a  long  and  minute  one,  but 
never  maundering,  wandering  or  whining.  His  com- 
panions will  tell  you  that  he  is  subject  to  great  fluctua- 
tions of  the  animal  spirits — gay,  even  fascinating  in 
society  ;  brisk,  orderly,  and  thorough  in  business,  but  at 
home,  dejected  or  fretful.  He  is  a  small  eater,  a  light 
sleeper,  and  a  worn  worker.'  Every  American  physician 
will  recognise  the  man.  I  will  not  attempt  to  place 
beside  this  brilliant  word -portrait  any  sketch  of  the 
neurotic  woman  ;  who  is  simply  the  counterpart  of  this 
man  with  the  difference  of  sex — a  female  copy,  in  fact, 
with  the  characteristics  accentuated. 

These  are  the  neurotic  or  Arab  beings,  in  whom  the 
vaso- renal  change  with  its  uric  acid  formation  runs  a 
course  I  will  now  try  to  portray. 

Digestive  Troubles. — In  the  large  majority  of  cases  the 
first  departure  from  health  has  been  disturbance  in  the 


64  V A  SO-RENAL  CHANGE. 

digestive  organs.  There  has  been  a  small  appetite,  dainty 
and  fastidious  often  in  childhood  at  an  age  when  other 
children  are  apt  to  be  coarse  feeders.  Scarcely  is  man- 
hood or  womanhood  attained  than  a  distinct  failure,  or  in- 
sufficiency, in  the  digestive  organs  becomes  apparent.  Any 
attempt  to  entice  them  to  take  food  like  other  people  only 
seems  to  aggravate  their  condition.  The  old  phrase  '  to 
feed  the  disease  and  not  the  patient,'  applies  to  this  class 
of  beings,  and  '  fits  them  like  a  glove.'  Their  feeble  appe- 
tite seems  the  guardian  of  their  insufficient  digestive 
organs.  Thanks  to  it,  the  latter  are  not  perpetually  over- 
taxed. Just  as  the  appetite  fails  when  the  liver  is  upset 
in  acute  conditions,  by  which  means  the  embarrassed 
viscus  is  protected,  whether  the  condition  is  due  to  phy- 
sical or  to  psychical  causes  ;  so  in  these  persons  a  small 
fastidious  appetite  secures  their  livers  from  being  over- 
burdened. All  attempts  to  induce  them  to  take  more  food, 
and  especially  animal  food  (under  the  impression  that  this 
will  make  them  strong),  end  in  disaster.  The  neurotic  has 
got  an  Arab  appetite,  and  does  best  on  Arab  fare.*  They 
are  dosed  with  chalybeates  in  vain,  and  to  no  purpose. 
Vegetable  tonics  are  apt  to  produce  such  vesical  irrita- 
bility that  they  have  to  be  given  up ;  as  regards  the  neurotic 
women  at  least.  Along  with  pain  after  food  (as  an  almost 
constant  condition,  unless  the  strictest  watch  be  kept 
against  any  indiscretion  in  diet)  there  is  apt  to  be  acidity 
and  flatulence.  One  day  the  one,  another  day  the  other. 
I  feel  certain  that  the  patient  who  complained  to  Ebstein 
that  '  one  day  he  was  a  vinegar  factory,  and  the  next  day 
a  gas  retort,'  was  a  neurotic  dyspeptic,  with  the  uric  acid 

°  A  typical  specimen  of  the  Arab  type  recently  told  me  she  was 
never  so  well  as  when  she  was  living  on  the  edge  of  a  desert. 


FIRST  STAGE.  65 

formation.  So,  too,  in  all  probability  was  the  old  clergy- 
man who  used  to  exclaim,  '  I  have  been  a  dyspeptic  fifty 
years;  thank  God  for  it  !'  The  cause  of  his  pious  grati- 
tude was  that  he  survived ;  while  all  his  brothers,  not 
so  protected,  had  died  of  some  form  of  gouty  trouble. 
Indeed,  looked  at  from  this  point  of  view,  the  indi- 
gestion is  really  a  guardian  angel,  and  a  blessing  in 
disguise. 

All  the  same,  it  is  this  very  digestive  disturbance  which 
sends  these  persons  to  the  physician's  door.  Sir  Thomas 
Watson  knew  this  class  of  patient  well.  He  wrote : 
*  Gouty  persons  are  subject  to  various  ailments,  which 
spring  from  the  same  fountain  as  the  well-marked 
paroxysm — derangements  in  the  functions  of  the  digestive 
organs,  of  the  heart  and  lungs,  of  the  brain  and  nerves. 
The  most  familiar  of  these  ailments  is  indigestion,  with  its 
.various  circumstances  of  impaired  appetite,  sickness, 
vomiting,  flatulence,  heartburn,  acid  eructation,  gastro- 
dynia.  The  bowels  are  irregular  ;  colicky  diarrhoea  being 
sometimes  the  prevailing  fault,  but  more  commonly  cos- 
tiveness.  With  all  this  the  patient  is  apt  to  be  excessively 
dejected  and  hypochondriacal,  morbidly  attentive  to  every 
bodily  feeling,  disposed  to  exaggerate  his  sufferings,  and 
apprehensive  of  the  worst  event.  When  the  viscera  and 
the  thorax  are  affected,  the  patient  has  palpitation,  fits  of 
dyspnoea,  faintings,  or  even  pangs  like  those  of  angina. 
In  the  head  occur  pain,  giddiness,  transient  affections  of 
the  vision  and  of  the  hearing,  threatenings  of  palsy  and 
apoplexy.  All  these  3'ou  may  say  are  feelings  and  ail- 
ments to  which  all  persons  are  liable.  True,  but  the  re- 
markable peculiarity  which  connects  them,  in  some  men, 
with  gout,  is  this — that  they  often  clear  away  and   dis- 

5 


66  V A  SO-RENAL  CHANGE. 

appear  upon  the  breaking  out  of  a  paroxysm  of  that  dis- 
ease in  the  foot.' 

[In  justice  to  myself  and  the  distinguished  author,  I 
must  explain  that  in  1871  I  gave  away  my  copy  of  his 
unparalleled  'Practice  of  Physic;'  and  it  was  only  after 
this  work  was  sketched  in  outline  that  a  copy  of  the  third 
edition  of  1848  was  purchased,  and  on  reading  over  the 
article  on  '  Gout,'  the  remarkable  fidelity  of  the  sketch 
was  vividly  realized.  Probably  had  I  got  another  copy 
earlier,  and  followed  it,  much  that  has  been  culled  from 
my  own  experience  might  have  been  made  clear  to  me 
by  that  work.] 

In  this  account  we  get  in  brief  most  of  what  is  about 
to  be  said.  The  digestion,  feeble  at  the  best,  is  liable  to 
be  upset  by  any  indiscretion  in  diet,  exposure  to  cold, 
bodily  exertion,  or  mental  perturbation.  As  the  bowels  of 
the  Hebrew  of  old  yearned  when  he  saw  his  younger 
brother,  so  the  neurotic — who  is  a  distinct  approach  to  the 
Semitic  Arab  and  Hebrew — when  emotionally  perturbed, 
feels  his  bowels  affected. 

Sometimes  the  pain  in  the  stomach  is  experienced  im- 
mediately after  food,  and  is  caused  by  deficient  secretion 
of  gastric  juice  (Leared),  and  is  certainly  relieved  very 
largely  by  a  dose  of  artificial  pepsin.  Not  infrequently 
there  is  a  certain  sense  of  distension  due  to  flatulence 
from  impaired  energy  in  the  muscular  wall  of  the  stomach. 
At  times  there  is  distinct  acidity  and  sour  eructations, 
possibly  due  to  the  presence  of  uric  acid  in  the  gastric 
•juice.  At  other  times  the  formation  of  a  fatty  acid  gives 
heartburn,  or  cardialgia,  and  at  other  times  pyrosis.  One 
American  dyspeptic  invariably  suffered  from  cardialgia  if 
he  tasted  warm  fat ;  though  he  could  eat  butter  when  cold 


FIRST  STAGE.  67 

and  enjoy  it.  Very  often  there  is  a  good  deal  of  hawking, 
with  mucus,  and  uncomfortable  feelings  in  the  pharynx. 
In  a  certain  proportion  of  these  cases  there  is  acidity  and 
pain  in  the  stomach,  which  is  relieved  by  taking  food. 
Here  there  is  a  quantity  of  acid  mucus  in  the  stomach. 
Very  often  nature  steps  in  and  gets  rid  of  the  acidity  by 
vomiting ;  and  where  this  is  not  the  case  an  emetic  gives 
great  relief. 

In  other  cases  the  pain  is  not  experienced  until  an  hour 
and  a  half  or  more  after  a  meal,  and  is  referred  to  the 
duodenum.  Here  it  would  seem  that  the  contents  of  the 
stomach  remain  very  acid  ;  and  the  chyme  is  not  neu- 
tralized by  the  bile  but  remains  acid,  with  the  result  of 
irritation  of  the  duodenal  mucous  membrane  ;  the  relief  of 
the  pain  so  produced  being  the  cause  why  the  patient 
seeks  the  physician.  The  complaint  is  also  of  losing 
flesh,  from  the  pancreatic  digestion  being  interfered  with 
by  the  acidity  of  the  chyme. 

Very  frequently  the  neurotic  victim  of  the  uric  acid 
formation  is  troubled  with  chronic  constipation.  Very 
often,  from  the  nature  of  the  dietary,  there  is  also  costive- 
ness.  Until  the  bowels  are  regulated  the  indigestion  and 
flatulence  persist,  no  matter  what  care  is  bestowed  upon 
the  dietary.  Mineral  waters  alone  are  too  cold  and  too' 
'  sloppy;'  and  a  small  pill,  consisting  of  hepatic  stimulants 
and  laxatives,  at  bedtime,  is  a  good  preparatory  step  to 
the  mineral  water  next  morning,  which  should  always  be 
taken  with  some  hot  fluid. 

When  these  neurotic  uric  acid  dyspeptics  are  run  down, 
or  reduced  from  any  reason,  they  are  liable  to  severe  pain 
along  the  transverse  colon.  The  pain  is  often  very  severe  ; 
and  in  character  seems  a  sort  of  hybrid  betwixt  neuralgia 

5—2 


68  VASO-RENAL  CHANGE. 

and  colic.  Sometimes  it  seems  to  be  in  the  stomach 
itself,  and  is  so  sudden  in  its  onset  as  to  bring  the  sufferer 
to  the  ground.  This  pain  seems  to  be  experienced  in  the 
worst  degree  by  persons  who  have  been  exposed  to 
malaria ;  and  one  of  the  most  marked  cases  that  ever 
came  under  my  notice  was  that  of  a  very  distinguished 
African  explorer,  who  had  had  malaria  over  and  over 
again. 

All  these  disturbances  are  due  to  the  presence  of  uric 
acid  in  the  blood  ;  and  my  own  opinion  is  identical  with 
that  of  Dr.  Garrod  on  the  matter.  He  says,  '  symptoms 
referable  to  the  digestive  organs  have  already  been  de- 
scribed as  being  frequently  premonitory  of  an  attack  of 
gout ;  but  it  is  not  uncommon  to  find  severe  and  pro- 
tracted dyspepsia  in  patients  who  have  never  suffered 
from  a  fit,  but  who  either  inherit  the  disease  very  strongly, 
or  have  sown  the  seeds  of  it  by  their  mode  of  living ;  and 
in  such  cases  the  derangement  of  the  digestive  organs  is 
doubtless  frequently  dependent  on  a  gouty  state  of  the 
blood.  It  is  often  a  matter  of  considerable  difficulty  to 
make  a  correct  diagnosis  in  these  instances  ;  but  at  times 
this  difficulty  is  at  once  removed  by  the  sudden  super- 
vention of  a  fit  of  articular  gout,  and  the  equallv  rapid 
disappearance  of  the  gastric  disturbance.  Such  relief, 
however,  is  not  always  experienced,  and  patients  may 
suffer  for  months  and  even  for  years  without  the  nature  of 
the  malady  being  discovered,  and  this  occurs  more  espe- 
cially in  persons  who  have  led  a  very  temperate  life,  but 
who  are  strongly  disposed  to  the  disease  :  slight  threaten- 
ings,  however,  of  the  toe  affection  are  sometimes,  on 
inquiry,  admitted  to  have  been  felt,  sufficient  in  many 
cases  to  render  the  pressure  of  the  boot  uncomfortable.' 


FIRST  STAGE.  69 

AYithout  a  knowledge  of  the  disturbances  of  the  digestive 
organs  linked  with  the  reversion  to  the  uric  acid  form- 
ation, a  correct  diagnosis  in  these  cases  is  simply  im- 
possible ;  '  the  eye  can  only  see  what  it  carries  with  it  the 
power  to  see,'  said  the  old  Italian  painters.  And  so  it  is 
in  these  cases.  While  without  it  satisfactory  treatment 
is  equally  out  of  the  question.  And  it  is  very  desirable 
that  there  should  be  a  more  general  recognition  of  the 
nature  of  these  cases,  as  they  are  frequent, — becoming  more 
frequent ;  and  are,  as  a  rule,  stumbling-blocks  to  the  pro- 
fession, and  especially  the  junior  members  of  it. 

Biliousness. — The  relations  of  what  is  termed  '  bilious- 
ness '  to  the  uric  acid  formation  are  interesting  and  in- 
structive. The  young  persons  who  are  liable  to  sick 
headaches ;  to  a  furred  tongue,  a  bad  taste  in  the  mouth 
in  a  morning,  with  sensations  of  depression  almost 
amounting  to  melancholia ;  with  dark  offensive  stools, 
sometimes  putty-like  ;  with  high-coloured  urine  ;  of  dark 
complexion,  belonging  to  the  class  known  as  being  of  '  the 
biliary  diathesis  ;'  and  who  are  liable  to  have  spots  of 
pain  which  '  can  be  covered  by  the  thumb-end  '  betwixt 
the  shoulders  or  just  outside  the  scapula — frequently 
become  goutv  as  middle  age  is  reached.  The  chemical 
relations  of  the  bile  acids  to  the  urates  and  urea  link  in 
with  this  clinical  observation.  Both  the  bile  acids  contain 
nitrogen  and  one  sulphur ;  distinctly  pointing  to  their 
descent  from  the  nitrogenized  elements  of  our  food.  That 
the  liver  which,  when  insufficient  or  incompetent,  errs  on 
the  side  of  bile  formation,  should  at  a  later  period  mani- 
fest a  reversion  to  the  uric  acid  formation,  is  pretty  much 
what  we  might  expect.  That  one  medical  man  should 
pronounce  these  spots  of  pain — usually  felt  in  the  neigh- 


70  V A  SO-RENAL  CHANGE. 

bourhood  of  the  scapula,  but  less  frequently  over  the 
pectoral  muscle,  especially  on  the  left  side,  and  when  so 
occurring  believed  to  be  connected  with  the  heart — to  be 
due  to  the  liver,  while  another  attributes  them  to  the 
kidneys,  is  intelligible  enough ;  for  they  are  found  with 
products  formed  by  the  liver  and  cast  out  by  the  kidneys. 
They  belong  to  that  not  yet  thoroughly  explored  territory 
of  the  retrograde  metamorphosis  of  nitrogenized  bodies. 
The  persons  who  experience  these  spots  are  either  the 
possessors  of  congenitally  inferior  livers,  or  who  have 
overtaxed  competent  livers  ;  and  though  such  persons  are 
liable  in  many  instances  to  '  bilious  sick  headaches,'  they 
usually  manifest  a  tendency  to  the  uric  acid  formation, 
sooner  or  later. 

On  this  subject  Dr.  Murchison,  in  his  famous  essay  on 
'  Functional  Derangements  of  the  Liver,'  writes  as  follows  : 
'Headache  is  not  an  unfrequent  result  of  hepatic  derange- 
ment. Most  commonly  it  takes  the  form  of  a  dull  heavy 
pain  in  the  forehead,  more  rarely  in  the  occiput,  com- 
plained of  as  the  patient  awakes  in  the  morning,  and 
either  speedily  ceasing  or  lasting  the  greater  portion  of 
the  day,  or  for  several  days.  Such  headaches  are  com- 
mon in  the  subjects  of  lithsemia  after  any  indiscretion  in 
diet,  or  when  the  bowels  are  constipated.  Their  imme- 
diate cause  is  probably  the  presence  in  the  blood  of  some- 
abnormal  product  of  albumen-metamorphosis ;  the  de- 
rangement of  the  liver  is  usually  indicated  by  pain  and 
fulness  in  the  right  hypochondrium,  flatulence  and  high- 
coloured  urine  loaded  with  lithates ;  and  relief  is  usually 
afforded  by  mercurial  and  saline  purgatives  and  alkaline 
diuretics.'  This  expression  of  opinion  by  Dr.  Murchison 
as  to  the  phenomena  being  due  to  some  product  of  '  albu- 


FIRST  STAGE.  71 

men-metamorphosis,'  quite  harmonizes  with  the  view 
taken  all  along  in  this  essay.  This  form  of  sick  headache 
seems  to  find  its  proper  locality  in  '  biliousness  ;'  while 
migraine  will  be  considered  later  on. 

So  much  then  for  the  troubles  of  the  gouty  neurotic  as 
regards  the  tissues  derived  from  the  foetal  hypoblast. 

Ski)i  Affections. — The  skin  is  liable  to  be  affected  in  all 
conditions  where  the  blood  is  of  toxic  character,  and 
laden  with  waste  matters  containing  nitrogen.  The 
itching  of  jaundice  is  well  known.  So  is  the  prurigo 
of  elderly  persons  whose  kidneys  are  probably  affected. 
Pruritus  ani  as  the  consequence  of  hepatic  derangement,  is 
a  notorious  clinical  fact.  Pruritus  vulva  is  also  found 
when  the  urine  is  of  irritant  character,  and  either  highly 
acid  or  charged  with  lithates.  When  there  is  a  quantity 
of  sugar  in  the  urine — a  very  common  occurrence  with 
persons  of  uric  acid  formation — the  irritation  set  up  is 
often  almost  unbearable.  Under  these  circumstances  it 
is  well  to  bathe  the  parts  with  some  warm  water  contain- 
ing some  carbonate  of  soda,  or  borax,  immediately  after 
micturition.  These  gouty  neurotics  are  also  liable  to 
furfuraceous  formations  on  the  epidermis. 

But  Herpes  is  the  malady  from  which  they  mostly  suffer. 
One  case  in  my  notebook  is  of  special  interest.  It  is  that 
of  a  lady  of  thirty-two,  a  gouty  neurotic,  whose  father 
died  of  paralysis,  and  her  mother  had  rheumatic  gout. 
She  was  a  delicate  child,  and  had  glandular  enlargement 
in  the  neck.  At  an  early  period  she  suffered  from  gall- 
stones. Her  catamenia  are  scanty,  and  accompanied  by 
much  pain.  She  has  a  furred  tongue  usually,  a  bad  taste 
in  her  mouth  in  the  morning,  and  a  foul  breath.  On  any 
excitement,  and  she  is  very  easily  excited  to  a  high  pitch, 


72  V A  SO-RENAL  CHANGE. 

she  suffers  from  great  vesical  irritability.  For  the  last 
nine  years  she  has  been  liable  to  patches  of  Herpes  Iris 
down  the  nerve-trunks  of  the  left  side,  whenever  her 
liver  is  upset  more  than  usual.  They  form  along  the 
nerve-trunks  of  the  palmar  aspect  of  the  forearm,  and 
along  the  sciatic  nerve.  A  curious  matter  connected 
with  them  is  that  they  always  occur  upon  the  left  side 
and  never  on  the  right.  Her  experience  is  that  she 
always  is  best  when  eating  little ;  but  that  she  is  con- 
stantly urged  by  friends  to  eat  more  than  she  feels 
inclined  to  do ;  and  that  when  so  induced  to  take  more 
food,  and  especially  animal  food,  she  is  always  the  worse 
for  it  and  not  the  better.  The  fact  that  herpes  is  a 
malady  of  the  epidermal  layer  of  the  epiblast  (in  which 
the  terminal  endings  of  the  cutaneous  nerves  ramify)  is  a 
not  uninteresting  fact  in  connection  with  the  neurotic  of 
the  uric  acid  formation,  and  liable  to  the  vaso-renal 
change. 

Migraine. — The  matter  of  migraine  has  just  been  alluded 
to  before.  Sir  Henry  Holland  in  connection  with 
migraine  made  this  observation :  '  There  is  reason  to 
believe  that  the  kidneys  are  the  excretory  organs  most 
concerned  in  giving  relief  in  these  cases,  and  principally 
by  an  increased  separation  of  lithic  acid  and  its  com- 
pounds.' 

Trousseau  regarded  it  as  a  manifestation  of  the  gouty 
diathesis.  Dr.  Liveing,  in  his  treatise  on  '  Megrim  and 
some  Allied  Disorders,'  regards  it  as  linked  with  the 
condition  of  lithiasis.  Dr.  Murchison  remarks  on  the 
severity  of  the  pain  ;  and  I  have  seen  a  lady  who  is  the 
subject  of  vaso-renal  change — a  gouty  neurotic — go 
delirious   with  the    agony    of  migraine.     The  pain   in    a 


FIRST  STAGE.  73 

mild  attack  is  in  and  around  the  eye — usually  the  right 
eye.  In  a  severe  attack  the  pain  extends  to  the  occiput  ; 
and  one  migrainous  lady  patient  put  it  thus  :  '  Whenever 
you  feel  the  pain  at  the  back  of  the  head  you  know  you 
are  in  for  a  bad  attack.'  Commonly  flashes  of  light  or 
stars  are  seen,  especially  in  severe  attacks  ;  but  this  does 
not  occur  with  all  migrainous  patients.  Usually,  but  not 
necessarily,  the  attack  goes  off  with  vomiting. 

There  is  a  periodicity  about  migraine  which  smacks  of 
lithiasis,  and  is  analogous  to  recurrent  attacks  of  articular 
gout.  This  matter  has  been  observed  by  Clifford  Allbutt, 
who  has  a  keen  eye  for  the  neurotic  in  all  forms.  He 
notes  some  associations  of  migraine  which  quite  tally 
with  my  own  observations.  '  A  painful  feature  of  some 
cases  of  migraine  is  the  sense  of  failing  inhibition  which 
some  persons  feel  before  the  explosion  occurs.  These 
sufferers  are  conscious  for  a  day  before  the  migraine  of  a 
weakened  control,  a  horrible  irritability  tending  to  rude 
or  passionate  acts  or  words,  which  are  restrained  by  most 
painful  efforts.  This  irritability  may  also  appear  as  a 
larval  migraine,  and  no  headache  appear,  so  that  its  true 
nature  may  be  undiscovered.  Other  persons  may  in  like 
manner  be  at  a  loss  to  explain  recurrent  states  of  nervous- 
ness with  cold  extremities  until  they  have  evidence  in  their 
own  persons,  or  in  the  person  of  a  relative  or  friend,  that 
such  things  are  a  fragment  of  a  cycle  which  in  them 
is  happily  incomplete.  Irritable  bladder  is  another 
symptom  which  accompanies  migraine  in  some  persons, 
and  passes  off  with  the  seizure.  In  one  of  my  patients 
this  symptom  occurred  at  times  without  the  development 
of  hemicrania,  though  clearly  of  the  same  nature  as  when 
headache    followed,    and    it    is    probable    that    in    other 


74  VASO-RENAL  CHANGE. 

persons  migraine  might  take  the  larval  form  of  recurrent 
vesical  irritation.'  This  last  matter  of  vesical  irritability 
in  neurotic  women  of  the  uric  acid  formation  is  far  too 
little  known,  or  recognised.  It  is  really  the  reason  why  so 
many  ladies  of  this  type  cannot  take  vegetable  tonics. 
And  though  they  do  not  volunteer  the  statement,  they  will 
readily  enough  admit  the  fact  when  the  question  is  put 
directly  to  them. 

Vertigo  is  often  experienced  with  migraine,  but  may 
occur  independently  of  it.  Vertigo,  swimming  feelings,  as 
If  stepping  on  a  loose  plank,  cramp,  itching,  flashes  of 
pain,  or  of  heat,  are  all  matters  familiar  to  those  who  suffer 
from  the  uric  acid  formation.  The  pain  of  herpes,  with- 
out eruption,  is  another  of  the  plagues  connected  with 
the  epidermal  layer  of  the  epiblast  in  such  sufferers. 

Mental  Phenomena. — Any  account  of  the  neurotic  in 
whom  the  vaso-renal  change  is  on  foot,  would  be  incom- 
plete without  some  reference  to  the  mental  phenomena. 
Speaking  one  day  to  a  lady  belonging  to  this  class,  and 
asking  her  if  the  psychical  semeia  should  be  omitted  from 
the  description,  the  prompt  and  decisive  reply  was  : 
'  Certainly  not !  They  play  a  most  important  part.'  She 
spoke  from  a  very  instructive  experience.  When  the 
blood  is  charged  with  bile-acids  (cholcemia)  the  mood  is  one 
of  sadness,  gloom,  and  depression  ;  the  horizon  seems, 
painted  in  with  Indian  ink  (melancholia).  When  the 
urates  are  circulating  freely  (lithcemia  or  lithiasis)  the  mood 
is  rather  that  of  irritability  and  explosiveness.  Nitrogen 
compounds  form  the  explosives.  And  explosions  of 
nervous  energy  are  common  phenomena.  The  leopard 
can  pounce  upon  the  antelope,  which  he  could  never  over- 
take by  chase,  because  the  carnivora  possess  the  power  of 


FIRST  STAGE.  75 

exploding  the  motor  centres  in  a  very  rapid  manner.  The 
sense  of  energy  and  well-being,  often  called  'fitness'  by 
the  athlete,  which  the  well-fed  man  enjoys,  has  constituted 
— in  conjunction  with  the  palate — a  large  factor  in  the 
meat-eating  tendencies  of  the  Anglo-Saxon.  But  when 
hepatic  reversion  is  on  foot,  then  bodies — the  products  of 
albumen-metamorphosis — possessing  distinctly  toxic  pro- 
perties are  formed.  Whether  these  bodies  are  formed  by 
the  impaired  liver,  or  they  are  formed  in  the  alimentary 
canal,  and  passing  into  the  portal  circulation  find  their 
way  through  the  incapable  liver  into  the  general  circula- 
tion, is  a  matter  not  yet  determined.  Just  as  the  liver 
normally  keeps  the  bile  within  the  portal  circulation,  but 
permits  it  to  escape  under  the  circumstances  which  pro- 
duce jaundice;  so  with  those  toxic  bodies.  Dr.  Lauder 
Brunton,  F.R.S.,  has  propounded  the  theory  of  ( the  liver 
as  a  porter  at  the  gate,'  standing  betwixt  the  portal  and 
the  general  circulation,  and  acting  as  a  filter ;  and  the 
more  the  subject  is  studied  the  more  the  idea  grows  upon 
one  as  one  studies  the  clinical  facts,  and  strives  to  unravel 
them. 

Dr.  Murchison  speaks  thus  of  depression  of  spirits  :  '  The 
influence  of  the  liver  upon  the  animal  spirits  has  been  recog- 
nised by  medical  writers  in  all  ages.  To  the  belief  in  the 
existence  of  such  an  influence  may  be  traced  the  origin  of 
such  terms  as  hypochondriasis  and  melancholia.  Although 
it  is  not  contended  that  the  morbid  states  of  mind  to 
which  at  the  present  day  we  apply  these  terms,  have  their 
origin  in  the  liver,  they  are  unquestionably,  in  many  in- 
stances, accompanied  and  aggravated  by  derangements  of 
this  organ.'  While  depression  of  spirits  and  groundless 
fears  are  the    common    accompaniments   of  hepatic  de- 


76  VASO-RENAL  CHANGE. 

rangement.  In  his  -  Psychological  Enquiries,'  Sir  Benjamin 
Brodie  speaks  as  follows  of  a  man  with  the  uric  acid 
formation  :  '  Uncomfortable  thoughts  are  presented  to  his 
mind ;  he  becomes  fretful  and  peevish,  a  trouble  to  him- 
self, and,  if  he  be  not  trained  to  exercise  a  moral  restraint 
over  his  thoughts  and  actions,  a  trouble  to  everyone  about 
him.  After  a  while  the  poison,  as  it  were,  explodes  ;  he 
has  a  severe  attack  of  gout  in  his  foot ;  he  is  placed  upon 
a  more  prudent  diet  ;  the  system  is  relieved  of  the  lithic 
acid  by  which  it  was  poisoned.  Then  the  gout  subsides  ; 
happy  and  cheerful  thoughts  succeed  those  by  which  the 
patient  was  previously  tormented,  and  these  continue 
until  he  has  the  opportunity  of  relapsing  into  his  former 
habits,  and  thus  earning  a  fresh  attack  of  the  disease/ 
Dr.  Murchison  classes  '  Irritability  of  Temper '  among  the 
symptoms  of  hepatic  derangement ;  and  Sydenham  re- 
alized the  mixture  of  irritability  and  apprehensiveness 
which  forms  the  mood  in  attacks  of  gout.  The  mental 
state  to  which  the  inhabitants  of  the  United  States  of 
America  apply  the  term  '  pure  cursedness,'  is  based  upon 
the  presence  of  products  of  albumen-metamorphosis  cir- 
culating in  the  blood.  There  is  often  an  irascible  temper, 
a  mood  of  savagery,  indeed ;  as  seen  in  the  latter  days  of 
King  Henry  VIII.,  who  was  a  fairly  amiable  personage 
in  his  early  days.  A  lady  who  experienced  these  abom- 
inable mental  states,  or  moods,  used  to  say  she  '  felt  as  if 
she  could  fight  with  a  feather ;'  and  the  victims  of  the 
uric  acid  formation  are  often  much  to  be  pitied,  especially 
the  neurotics.  The  gouty  Norse  type  of  being  is  often  a 
hard  thinker  of  great  mental  activity  and  sound  judgment; 
but  hasty  in  temper  and  passionate.  But  the  neurotic 
of  the  uric  acid  formation  is  a  person  who  suffers  much 


FIRST  STAGE.  77 

and  deserves  our  sympathies.  If  they  are  trying  to  others 
they  are  a  still  greater  trial  to  themselves ;  and  we  should 
make  as  many  allowances  for  the  gouty  brain  as  we  do 
for  the  gouty  foot.  We  do  not  expect  an  elastic  step 
with  a  gouty  foot ;  neither  should  we  expect  calm  mental 
working  with  a  gouty  brain.  Indeed,  it  is  possible  to  lay 
much  infirmity  of  temper,  much  of  human  frailty,  to  the 
charge  of  uric  acid. 

One  lady  says  her  feeling  in  a  gouty  mood  is  pretty 
much  that  of  '  Just  let  me  alone  ;'  that  trifles  create  more 
wrath  than  their  importance,  or  rather  insignificance, 
warrants.  Little  things  irritate  out  of  all  proportion  to 
their  magnitude.  The  mood  is  irascible  and  explosive. 
And  especially  is  this  the  case  where  sleeplessness  exists. 
Sleepless  persons  with  the  uric  acid  formation  are  angry, 
combative  beings,  greatly  given  to  support  the  negative, 
or  exhibit  unbelief.  When  they  lay  their  heads  upon  the 
pillow,  instead  of  dropping  off  to  sleep  readily  and  calmly, 
they  toss  and  turn  ;  or  the  thoughts  wander  off,  work  in  a 
circle,  and  come  back  to  their  starting-point,  having  run 
a  useless  course  ;  simply  unprofitable  thinking,  and  con- 
trasting with  that  clear,  calm  thought  wdiich  comes  to  one 
sometimes  in  the  watches  of  the  night.  Or  they  drop  off 
and  have  unpleasant  dreams,  often  awakened  by  night- 
mare. Nor  is  this  surprising.  That  when  the  thoughts  are 
tinged  with  sadness  in  the  day,  the  dreams  will  have  the 
hue  of  melancholia,  is  comprehensible  enough.  Towards 
the  hour  of  rising  the  sleepless  being  falls  into  a  com- 
paratively sound  sleep ;  and  on  getting  up  feels  unrested 
and  irritable  and  quarrelsome.  No  wonder,  then,  the 
lady  thought  the  mental  phenomena  '  play  an  important 
part.' 


78  VASO-RENAL  CHANGE. 

Cardiac  Neuroses. — Another  distinct  group  of  troubles  is 
found  with  the  neurotic  victim  of  the  uric  acid  formation, 
which  is  linked  with  the  circulatory  organs;  and  especially 
the  centre — the  heart.  It  has  been  pointed  out  in  a  pre- 
ceding chapter,  that  when  there  is  an  obstruction  offered 
to  the  flow  of  the  blood  in  the  peripheral  vessels,  this 
leads  to  a  damming  of  the  blood  in  the  arteries,  and  a  rise 
in  the  blood-pressure  therein  ;  with  the  consequence  of 
hypertrophy  (more  or  less  perfect)  in  the  left  ventricle. 
In  time  there  is  developed  hypertrophy  of  the  muscular 
fibre  at  both  ends  of  the  circulation,  with  high  arterial 
tension.  But  there  are  times  when,  from  some  cause 
(probably  an  unusual  amount  of  nitrogenized  waste  in  the 
blood),  there  is  set  up  a  condition  of  arteriole  spasm,  and 
thus  we  get  attacks  of  angina  pectoris  vasomotoria ;  a 
malady,  which  will  be  reviewed  at  some  length  in  the 
next  chapter.  Sometimes  there  is  palpitation  of  the 
heart, — as  the  left  ventricle  struggles  to  overcome  the 
resistance  offered  by  the  high  blood  -  pressure  in  the 
arteries.  This  is  the  form  of  palpitation  which  occurs 
without  effort  and  without  excitement.  It  comes  on 
when  the  individual  is  perfectly  quiet ;  indeed,  it  not 
unfrequently  wakens  its  victim  from  sleep,  and  comes  like 
a  thief  in  the  night.  It  occurs  with  individuals  whose 
cardiac  hypertrophy  may  be  perfect ;  as  well  as  when  the 
hypertrophy  is  diluted  with  dilatation.  In  persons  whose 
hearts  exhibit  a  combination  of  hypertrophy  and  dilata- 
tion, palpitation  may  also  be  excited  by  effort;  which  may 
mislead  the  unwary  practitioner.  But  the  great  matter  to 
remember  is,  that  the  palpitation  of  vaso-renal  change  is 
due  to  vaso-motor  spasm  ;  and  occurs  independently  of 
effort,  or  of  exertion,  or  excitement. 


FIRST  STAGE.  79 

At  other  times  an  intermittent  pulse  is  the  result  of  a 
condition  where  the  blood  is  surcharged  with  nitrogenized 
waste.  It  is  apt  to  become  a  formed  habit  as  years 
advance,  and  many  old  persons  have  such  a  pulse  going 
on  for  years;  constantly  and  unceasingly  intermittent,  but 
free  from  any  sinister  significance.  The  late  Dr.  Archi- 
bald Billing,  the  Nestor  of  the  London  profession,  had 
such  an  intermittent  pulse  for  a  number  of  years  before 
his  death.  But  this  intermittency  may  occasionally  be 
found  in  a  person  of  neurotic  diathesis  at  a  comparatively 
early  period  of  life. 

There  is,  however,  a  much  more  clinically  interesting 
disturbance  of  the  heart's  action  beginning  to  present 
itself  to  our  vision ;  which  is  not  spoken  of  by  earlier 
writers  on  the  heart — because,  in  my  belief,  they  did  not 
encounter  it.  It  is  only  of  late  years  that  I  have  met  with 
it,  or  at  least  recognised  it,  to  put  it  very  cautiously.  Sir 
Thomas  Watson,  in  a  passage  quoted  early  in  this  chapter, 
spoke  of  '  faintings '  in  connection  with  the  nervous  phe- 
nomena of  gout  ('  Faintings,  or  even  pangs  like  angina  '). 
Consequently,  these  attacks  must  have  come  more  or  less 
under  his  notice.  They  are  attacks  to  which  Professor 
Gairdner  has  given  the  term  Angina  sine  Dolor e.  There 
is  none  of  that  acute  physical  agony  which  accompanies 
the  distension  of  the  aortic  root.  The  features  are  those 
of  angina  during  the  attack.  The  attack  commences  by 
the  extremities  becoming  cold  ;  the  muscular  system  is 
relaxed,  the  patient  lies  flat  on  the  back ;  the  heart's 
energy  wanes,  the  pulse  is  small,  feeble,  and  compressible. 
It  is  syncope  without  the  loss  of  consciousness.  The 
sufferer  has  the  keenest  realization  of  the  bitterness  of 
dissolution.     In  angina  the  agony  of  the  pain  diverts  the 


So  V  A  SO -RENAL  CHANGE. 

patient's  attention ;  but  here  the  patient  lies  powerless, 
motionless,  as  if  paralyzed  with  curara ;  yet  with  the 
consciousness  unclouded,  and  every  sense  on  the  stretch, 
till  the  beating  of  the  wings  of  the  Angel  of  Death  become 
distinctly  audible.  I  have  heard  such  patients  comparing 
notes,  and  the  situation  must  be  one  of  singular  horror. 
I  have  had  personal  experience  of  the  pain  of  severe 
articular  gout ;  but  it  cannot  approach  the  psychical 
suffering  of  these  terrible  experiences.  I  have  seen  even 
stalwart  men  unnerved  and  shaken,  till  they  felt  like  an 
incarnate  aspen  leaf  after  an  attack  of  this  kind  ;  and  to 
feel  utterly  demoralized  after  them.  Such  a  patient  has 
lain  upon  the  couch  in  my  consulting-room  for  two  hours, 
all  but  pulseless,  with  a  bed  hot-water  bottle  over  the 
heart.*  Another  has  lain  down  on  the  floor  till  his  hour 
was  past.  After  a  series  of  them,  I  have  seen  a  medical 
man,  not  lacking  in  courage,  looking  as  if  haunted,  with 
his  nervous  system  terribly  shaken — so  shaken  that  he 
could  scarcely  exercise  self-command.  It  must  be  a 
terrible  experience,  this  psychical  pain  in  these  attacks. 
In  swooning,  or  syncope,  the  victim  is  fortunate  enough 
to  'go  off  completely,'  and  becomes  unconscious;  but 
these  unhappy  beings  are  less  fortunate,  and  distinctly 
realize  all  the  horror  of  the  situation.  These  seizures 
vary ;  sometimes  the  attack  goes  off  in  a  few  minutes 
after  some  brandy  and  water  is  taken ;  at  other  times 
they  last  two  hours  or  more.  Their  recurrence  is  fitful. 
Sometimes  a  number  occur  within  a  few  days.     In  other 

°  That  this  was  really  suppressed  gout  is  pretty  fairly  proved  by 
the  fact  that  articular  gout  led  to  an  anti-gout  line  of  treatment  being 
adopted  ;  with  the  result  of  relief  from  these  attacks,  except  in  a  very 
shadowy  form. 


FIRST  STAGE.  81 

cases  the  interval  consists  of  months.  We  have  not  yet 
had  enough  familiarity  with  them  to  speak  with  any  sense 
of  sureness  about  them.  The  effect  of  uric  acid  solvents 
point  to  their  association  with  the  uric  acid  formation. 

In  angina  there  is  high  arterial  tension  and  a  tight 
artery,  followed  by  a  free  flow  of  pale  watery  urine.  There 
is,  then,  either  (i)  this  arteriole  spasm  extending  to  and 
including  the  coronary  circulation,  and  so  lowering  the 
action  of  the  heart ;  or  (2)  the  arteriole  spasm  is  linked  with 
some  irritation  of  the  roots  of  the  inhibitory  fibres  of  the 
vagus,  for  the  pulse  is  at  once  slow  and  feeble,  and  the 
secretion  of  urine  not  increased,  certainly.  Whichever  of 
these  is  the  true  solution,  there  is  great  loss  of  tone  in  the 
arterial  system,  and  the  blood-supply  to  the  brain  is 
largely  cut  off — leaving  the  sensorium  in  the  most  miser- 
able condition  of  psychical  distress. 

In  angina  we  know  there  is  a  distinct  element  of  danger 
of  the  heart  coming  to  a  standstill  in  diastole ;  especially 
when  the  muscular  structure  is  undermined  by  necrobiotic 
changes,  and  fatty  degeneration  is  afoot.  We  know,  too, 
that  fatal  syncope  may  occur  in  debilitated  conditions  of 
the  system,  even  without  any  organic  change  in  the  heart. 
But  what  amount  of  danger  to  life  attaches  to  these 
attacks  of  vascular  asthenia  is  as  yet  unknown.  So  far 
as  my  own  personal  experience  goes,  no  disaster  has 
occurred,  as  yet  at  least.  And  one  case  is  known  to  me 
where  an  old  lady  has  been  subject  to  such  attacks  for 
twenty  years.  At  first  they  caused  great  alarm,  both  to 
herself,  and  all  around  ;  but  the  course  of  time  and  ex- 
perience have  allayed  these  fears,  and  all  take  them  pretty 
much  as  a  matter  of  course,  her  son  informs  me — who  is 
himself  a  neurotic  of  the  uric  acid   formation,  and  the 

6 


82  VASO-RENAL  CHANGE. 

victim  of  migraine.  If  they  are  not  fraught  with  danger 
to  life,  and  do  not  threaten  the  patient's  existence,  they 
certainly  can  be  counted  as  among  the  most  trying  ordeals 
to  which  frail  and  suffering  humanity  is  liable. 

So  much  then  for  the  maladies  implicating  the  hypo- 
blast and  the  epiblast  in  the  vaso-renal  change. 

Some  Practical  Points. — While  the  attempt  to  contrast 
the  course  run  by  this  change  with  the  uric  acid  formation 
in  persons  of  the  Norse  type  with  its  progress  in  the 
neurotic  or  Arab  type,  is  made  in  order  to  throw  the  sub- 
ject up  in  vivid  outline  ;  there  is  no  design  to  hide  the 
clinical  fact,  that  there  is  much  blending  and  intertwining 
of  the  phenomena  in  actual  practice.  A  person  of  the 
neurotic  class  will  manifest  unmistakable  articular  gout, 
or  cardiao-vascular  changes  ;  while  another  of  unmistak- 
ably the  Norse  type  may  be  liable  to  cardiac  neuroses. 
One  of  these  latter,  a  man  of  as  stalwart  physique  as  any 
of  his  ancestors  as  far  back  as  the  Danish  viking  who 
steered  his  pirate  war-keel  to  the  shores  of  England,  is 
liable  to  the  seizures  of  the  vascular  failure  just  described. 
On  the  other  hand,  one  of  my  out-patients  at  the  Victoria 
Park  Hospital  at  the  present  time  is  a  pallid  slight  girl  of 
seventeen,  complaining  of  indigestion,  acidity,  and  flatu- 
lence, migraine  and  vesical  irritability,  with  her  urine 
constantly  loaded  with  lithates ;  who  already  has  got  a 
tight  artery,  a  large  heart,  and  a  loud  aortic  second  sound. 
What  the  future  history  of  that  girl  will  be,  is  of  course 
unknown  to  me  ;  but  it  seems  exceedingly  unlikely  that 
she  will  ever  attain  length  of  days.  Another,  a  slightly- 
built  Jewess  of  twenty-nine,  complaining  in  a  like  manner 
of  digestive  troubles,  with  lithates  in  her  urine  for  years 
past,  has  not  only  got  a  hard  artery,  a  large  left  ventricle, 


FIRST  STAGE.  83 

a  loud  aortic  second  sound  ;  but  there  are  evidences  of 
secondary  valvulitis  (mitral).  One  of  my  patients,  a 
Devonshire  squire  of  far  extending  lineage,  gave  an  almost 
ideally  perfect  account  of  the  troubles  of  a  blend,  or  hybrid. 
In  early  life  he  was  subject  to  bilious  attacks.  At  the 
age  of  thirty-four  he  had  his  first  twinge  of  gout  in  his 
great  toe.  So  little  has  the  gout  attacked  his  articulations, 
that  now  at  the  age  of  sixty  he  walks  ten  hours  a  day. 
For  fifteen  years  he  has  had  gastric  acidity  and  flatulence, 
is  liable  to  spots  on  his  skin,  has  had  psoriasis  palmaris, 
and  now  has  cramps ;  while  his  urine  is  free  from 
sediments — as  the  urine  of  the  Norse  type  of  man  is  very 
apt  to  be ;  contrasting  with  the  lithates  found  in  the  urine 
of  persons  of  the  neurotic  type.  In  another  patient,  a 
Kentuckian,  the  mixture  of  semeia  was  conspicuous.  He 
was  a  perfect  gouty  Arab,  of  large  head  and  thin  flank, 
whose  father  died  of  apoplexy.  He  complained  of  acidity 
and  flatulence,  palpitation,  cold  hands  and  feet ;  while  his 
left  hand  burns  at  times  ;  he  is  liable  to  urticaria,  and 
subject  to  the  most  horrible  sensations  at  times,  evidencing 
maladies  of  the  epiblast  and  hypoblast ;  yet  he  has  a  large 
heart,  hard  arteries  and  emphysema,  belonging  to  the 
tissues  of  the  mesoblast.  In  another  case,  a  lady  who 
consulted  me  for  indigestion,  acidity,  and  flatulence,  with 
red  sediments  in  her  urine  habitually,  was  seamed  and 
scarred  with  eczema. 

It  is  unnecessary  to  multiply  cases  of  these  hybrids, 
manifesting  at  one  and  the  same  time  the  troubles  of  both 
types.  They  may  occur  in  any  and  varying  proportions. 
All  the  same,  this  vaso-renal  change  with  reversion  to  the 
uric  acid  formation  runs  a  distinctly  definite  and  different 
course  in  the  person  of  the  Norse  type,  and  in  another  of 

6—2 


84  V  A  SO-RENAL  CHANGE. 

the  neurotic,  or  Arab  type.  To  see  a  chronic  and  pro- 
longed pathological  process  running  a  distinctly  varying 
course  in  different  classes  of  persons,  is  a  clinical  matter 
of  the  highest  importance  at  the  present  time.  Since  the 
introduction  of  instruments  of  precision  and  the  develop- 
ment of  physical  examination,  medical  teaching  has  gone 
away  from  the  old  lines  of  temperaments  and  diatheses, 
and  attached  itself  tenaciously  to  physical  signs. 

The  student  of  to-day  is  taught  to  look  too  exclusively 
to  the  disease  ;  and  too  little  at  the  individual  in  whom  the 
disease  exists.  Yet  the  consideration  of  this  chapter  ought 
to  induce  him  to  ponder  and  reflect  upon  the  different 
course  taken  by  a  protracted  morbid  change,  according  to 
the  individual  in  whom  it  is  on  foot. 

There  is  no  attempt  made  here  to  ride  a  hobby  to 
death  in  the  division  made  of  the  Norse  and  neurotic 
types.  The  division  has  the  approval  of  some  of  our 
very  best  observers  and  clinical  teachers. 

Another  matter  is  this  :  In  this  consideration  of  the 
vaso-renal  change  the  renal  element  has  not  been  paraded, 
but  rather  kept  in  the  background.  This  is  in  accord- 
ance with  clinical  facts.  In  the  bulk  of  cases  the  kidney 
plays  a  passive  part  until  the  later  stages  are  reached. 
Certainly  in  some  cases  the  kidneys  force  themselves 
upon  the  attention  at  a  comparatively  early  period  ;  but 
this  is  not  the  rule.  Why  they  should  do  so  in  one  case 
more  than  another,  may  be  due  at  times  to  some  acci- 
dental chill  or  exposure,  which  engrafts  tubular  nephritis 
upon  a  system  entered  upon  this  vaso-renal  change  ;  and 
such  seems  to  me  were  the  cases  Dr.  Bright  described  in 
his  first  report.  It  is,  of  course,  simply  impossible  to  say 
why  in  one  person  the  cardiao-vascular  changes  are  the 


FIRST  STAGE. 


85 


more  pronounced  ;  in  another,  articular  gout  is  the  promi- 
nent matter  ;  while  a  third  has  chronic  bronchitis  ;  and 
a  fourth  eczema  as  the  plague  of  their  lives :  while  in 
other  cases  again,  like  that  recorded  by  Dr.  Headlam 
Greenlow,  one  form  of  trouble  alternates  with  another  in 
regular  sequence. 

One  matter  is  curious,  interesting,  and,  what  is  more,  of 
high  diagnostic  value.  It  is  connected  with  the  epidermal 
section  of  the  epiblast,  viz.,  the  constancy  with  which  the 
teeth  and  nails  are  affected.     The  teeth  are  worn  down 


Fig.  6. 

and  blunted  at  the  edge  ;  at  first  slightly,  subsequently 
till  they  look  more  like  pegs  than  edged  cutting-instru- 
ments. This  change  is  seen  in  this  illustration  very 
clearly,  though  at  an  early  stage.  It  is  one  of  a  number 
of  casts  taken  by  Dr.  William  Stewart,  and  exhibited  by 
him  at  the  Harveian  Society  of  London,  after  some 
remarks  made  by  myself  as  to  the  changes  in  the  teeth  of 
gouty  persons.  Persons  of  the  uric  acid  formation  exhibit 
retraction  of  the  gum  from  the  crown  of  the  tooth,  with  a 
frequency   common   enough  to   give  the  phenomenon    a 


86  V  A  SO-RENAL  CHANGE. 

distinct  diagnostic  value.  As  soon  as  this  matter  catches 
the  eye,  the  clue  is  often  given  to  the  patient's  malady ; 
which  otherwise  may  be  obscure.  This  is  associated  with 
a  process  by  which  the  tooth  becomes  loose  in  its 
socket  ;  very  often  there  is  inflammatory  osteitis  at  its 
root,  and  maybe  a  bony  growth  along  the  fang.  Such 
teeth  are  liable  to  fall  out  sound,  and  free  from  caries  ;  and 
in  some  individuals  all  the  teeth  come  out  in  this  manner. 
In  others  some  come  out  without  caries;  while  others  along- 
side them  evince  signs  of  decay.  But  speaking  broadly, 
when  the  teeth  come  out  sound  and  undecayed  they 
suggest,  if  not  something  more,  the  uric  acid  formation. 

Another  matter  is  that  of  the  nails,  which  are  modifica- 
tions of  the  epidermis,  and  consist  of  agglutinated  hairs. 
The  tendency  of  the  uric  acid  formation  is  to  deteriorate 
the  nail,  and  reveal  its  structure ;  whether  it  is  the 
imperfect  nail  of  the  strumous  child,  or  a  change  to  be 
noted  in  nails  of  much  primitive  excellence.  A  reediness, 
or  striation  of  the  nails  may  commonly  be  noted  in 
dyspeptic  women  under  thirty,  who  pass  quantities  of 
lithates  ;  and  is  as  significant  of  the  uric  acid  formation 
as  is  a  gradual  change  in  the  nails  of  a  person  of  Norse 
type  fifteen  years  later  in  life. 

The  accompanying  illustration  shows  this  reediness, 
and  also  furnishes  a  very  instructive  story.  A  friend  and 
patient  of  mine,  Dr.  John  Archibald,  consulted  me  for 
gouty  phenomena  of  a  mixed  order  in  the  autumn  of 
1884.  He  was  put  upon  an  anti-gout  regimen,  with  much 
benefit.  Soon  he  noticed  a  change  in  his  nails.  The 
old  nail  was  reedy,  the  new-coming  nail  was  smooth ;. 
the  change  dating  from  the  time  he  came  under  treat- 
ment.    When  the  nail  was  half  grown — the  distal   end 


FIRST  STAGE. 


87 


being  reedy,  while  the  proximal  end  was  smooth — the 
thumb  was  photographed  ;  and  presented  the  appearance 
seen  in  b.  A  little  later  the  reedy  portion  has  been 
worn   off,    and    the    nail    was    smooth,    c.     As    no    such 


Fig.  7. 

modification  of  the  nails  had  been  anticipated,  or  dreamt 
of,  of  course  no  photograph  existed  of  the  original  state 
of  the  nail.  A  ladyfof  like  age,  and  of  gouty  proclivities, 
supplied  a  nail  bearing  a  very  close  resemblance  to  the 
original  nail,  0.* 

Another  sign  has  just  had  my  attention  drawn  to  it  by 
an  old  physician,  viz.,  vascularity  of  the  inner  surface 
of  the  lower  eyelid.  So  far  as  my  observations  have 
gone  this  semeion  has  a  value. 

When  there  exist  (1)  reedy  nails;  (2)  blunt  teeth; 
(3)  a  loud  aortic  second  sound  ;  and  (4)  a  distinct  mental 
irritability  at  times,  contrasting  with  the  usual  mood: 
the  diagnosis  of  the  uric  acid  formation  (even  with  a 
clear  urine)  in  a  person  of  Norse  type  is  pretty  certain 
without  any  articular  gout.  While  acidity,  flatulence, 
indigestion  and  the  presence  of  urates  in  the  urine  tell  as 
plainly  of  it  in  the  neurotic,  or  Arab.  Such  then  is  the 
vaso-renal  change  in  its  early  stages. 


The  artist  has  slightly  exaggerated  the  striation  in  b ;  but  certainly 


not  as  to  a. 


88  VA SO-RENAL  CHANGE. 

One  more  point  to  be  attended  to  is  the  difference  in 
the  renal  secretion  in  the  two  classes.  The  Norse  squire, 
with  his  large  heart  and  tense  artery,  passes  a  large 
quantity  of  urine,  rarely  depositing' lithates,  except  at  the 
time  of  a  cold ;  whilst  in  the  neurotic  the  urine  usually 
manifests  lithates. 

The  amount  of  urea  passed  in  the  first  case  is  consider- 
able ;  while  less  is  known  about  its  proportion  in  the 
latter  instance.  The  Norseman,  whose  liver  is  over-taxed 
chronically,  retains  for  long  a  good  urea  formation  j  though 
the  tendency  to  uric  acid  formation  deepens  with  time. 
In  the  neurotic,  or  Arab  type,  there  exists  an  impairment 
of  the  glandular  derivatives  of  the  hypoblast  from  the 
first ;  and  the  urea  formation  seems  defective  from  a  com- 
paratively early  period.  Consequently,  though  the  dietary 
is  a  spare  one,  and  animal  food  is  eschewed — often  appar- 
ently from  an  instinctive  choice  —  there  exist  lithates 
habitually  in  the  urine  ;  and  in  those  persons,  as  a  very 
competent  physician  (Dr.  William  H.  Broadbent)  observed 
one  day,  '  it  is  almost  impossible  to  prevent  the  formation 
of  lithates.' 

By  an  appropriate  dietary  and  regimen  the  uric  acid 
formation  can  be  kept  well  in  hand  in  persons  of  the 
Norse  type ;  but  with  the  other  class  the  most  careful 
attention  to  the  dietary  does  not  yield  quite  satisfactory 
results ;  while  the  uric  acid  solvents  (potash  or  lithia), 
usually  so  successful  in  gouty  cases  of  the  Norse  type, 
are  not  well  borne  (especially  potash)  by  individuals  of 
the  neurotic,  or  Arab  type.  Consequently,  we  may  fairly 
safely  conclude  that  the  physician  can  render  greater 
services  to  the  gouty  Norseman  than  is  possible  in  the 
case  of  the  neurotic  lady  with  the  uric  acid  formation. 


CHAPTER  IV. 

MIDDLE      STAGE. 

a.  Diseases  of  the  Vascular  System:  Palpitation— Angina  Pectoris 
Vaso-motoria  —  Epistaxis  —  Atheroma  —  Aneurysm  —  Apoplexy  — 
G'rangrene. 

b.  Changes  in  the  Kidney :  Interstitial  Nephritis— Tube-casts— The 
Urine — Albuminuria — Glycosuria. 

c.  Results  of  Toxic  Blood:  Uraemia — Secondary  Inflammations  — 
Gouty  Asthma— Albuminuric  Retinitis— Dupuytren's  Contraction. 

Some  Practical  Points. 

The  vaso-renal  change  pursues  its  way  steadily  along  the 
lines  laid  down  in  the  preceding  chapter,  for  years,  and 
usually  many  years ;  my  strong  impression  being  that  it 
runs  a  slower  course  (perhaps  from  its  being  more  amen- 
able to  treatment)  in  persons  of  the  Norse  type,  than  in 
those  of  the  neurotic,  or  Arab  type.  In  other  words,  from 
the  point  of  view  of  the  Insurance  Office,  the  Norse  type 
is  the  better  life.  As  age  advances,  the  neurotics  seem 
to  exhibit  a  tendency  to  take  on  the  changes  in  the 
vascular  system  ;  and  to  add  the  dangers  accruing  there- 
from to  the  troubles  with  which  they  are  already  familiar. 
Consequently,  a  single  line  of  progress  will  now  be  adopted 
as  being  most  in  harmony  with  the  actual  clinical  facts. 

We    find    (i)    diseases    connected    with    the    vascular 
system ;  (2)  changes  in  the  kidney ;  and  (3)  diseases  due 


9o  V A  SO-RENAL  CHANGE. 

to  the  vitiated  condition  of  the  blood,  coming  into  view. 
And  in  this  order  will  the  troubles  of  the  middle  stage  be 
discussed. 

Diseases  of  the  Vascular  System. — These  can  be  sub- 
divided into  those  due  to  spasm  of  the  arterioles ;  and 
those  due  to  the  waxing  rigidity  of  the  arterial  walls,  in 
connection  with  the  large  left  ventricle. 

The  first  section  embraces  rather  disorders  than  dis- 
eases from  a  pathological  point  of  view ;  but  '  diseases ' 
they  certainly  are,  in  the  truest  and  original  sense  of  the 
word,  from  a  clinical  point  of  view.  They  include  palpita- 
tion, and  Angina  pectoris  vaso-motoria. 

Palpitation. — When  the  condition  of  arteriole  spasm  is 
set  up  in  the  hypertrophied  arterioles,  and  the  blood-flow 
out  of  the  arterial  system  is  obstructed,  there  is  a  rise 
in  the  blood-pressure  within  the  arteries — of  a  depurative 
nature  on  the  whole.  The  obstruction  so  offered  to  the 
contraction  of  the  left  ventricle  on  systole  is  increased ;  and 
then  the  heart  palpitates,  as  the  larger  ventricle  struggles 
against  the  resistance  offered  to  its  contraction.  Such 
palpitation  is  obviously  not  connected  with  general  efforts 
but  is  due  to  conditions  of  the  blood ;  by  which  the 
arterioles  are  incited  to  contract.  It  is  not  the  palpita- 
tion of  a  feeble  muscular  wall  requiring  digitalis,  and 
allied  cardiac  tonics  ;  but  rather  remedial  agents  which 
will  sweep  the  offending  matters  out  of  the  blood.  Of 
course,  where  the  toxic  condition  of  blood  co-exists 
with  a  feeble  heart-wall,  a  complex  pathological  state 
may  necessitate  an  equally  complex  treatment ;  and  the 
two  classes  of  remedial  agents,  cardiac  tonics  and  blood- 
purifiers,  must  be  used  together. 

Angina  Pectoris   Vaso-motoria. — The  great  matter,  howr 


MIDDLE  STAGE.  91 

ever,  connected  with  the  hypertrophy  of  the  muscular 
wall  of  the  arterioles,  is  that  dread  disease  '  breast-pang,' 
or  Angina  pectoris  vaso-motoria.  There  is  a  form  of 
neuralgia  of  the  cardiac  plexus  which  causes  acute  suffer- 
ing ;  and  simulates  true  breast-pang,  and  is  known  as 
spurious  angina — which  lies  outside  the  present  inquiry.* 
Here  we  are  dealing  with  Angina  pectoris  vaso-motoria 
(Eulenberg). 

From  the  consideration  of  the  effect  of  blood  laden 
with  nitrogenized  waste  upon  the  vaso-motor  centre  and 
the  consequent  rise  in  arterial  tension,  as  a  means  of 
depurating  the  blood,  in  Chapter  II.,  it  would  seem  that 
Angina  pectoris  vaso-motoria  is  but  an  acute  exacerbation 
of  the  chronic  condition.  During  it  the  condition  of 
high  arterial  tension  is  intensified ;  and  a  large  output  of 
urine  is  the  resultant  consequence  of  the  attack. 

Whether  this  may  ultimately  turn  out  to  be  the  true 
explanation  of  the  effect  of  blood  laden  with  nitrogenized 
waste  upon  the  vaso-motor  nerves,  or  nerve-centre,  or 
not,  we  know  clinically  that  it  is  in  the  persons  under- 
going the  vaso-renal  changes  we  find  true.  Angina  pectoris 
vaso-motoria.  Being  a  neurosal  affection,  it  stands  to 
reason — and  experience  demonstrates  it  as  a  fact — that 
angina  is  much  more  frequent  with  the  neurotic  than  the 
Norse  type.  The  famous  John  Hunter,  the  anatomist, 
is  a  case  in  point.  Though  a  neurotic,  he  underwent 
the  vascular  changes  of  the  uric  acid  formation.  My 
personal  experience  of  practice  runs  strongly  in  the 
direction    of    angina    belonging,    by   preference,    to    the 

9  In  my  experience  'spurious  angina,'  or  cardiac  neuralgia,  is 
essentially  a  malady  of  women  ;  whereas  true  angina  (vaso-motoria) 
is  rather  a  malady  of  men. 


92  V A  SO-RENAL  CHANGE. 

neurotic,  or  Arab  beings.  It  shows  itself  in  them  not  un- 
commonly about  the  age  of  forty.  Such  sufferers  are 
often  all  the  more  alarmed  from  the  fact  that  very  fre- 
quently a  relative  (commonly  a  father)  died  of  angina. 
And  when  the  sufferer  arrives  at  the  age  at  which  his 
father  died,  i.e.,  from  sixty-five  to  eighty,  he  in  turn  may 
also  die  of  angina.  But  angina  in  comparatively  young 
persons  whose  heart-walls  are  structurally  sound,  is  not 
fraught  with  much  danger  to  life.  The  case  of  Dr. 
Arnold,  of  Rugby,  may  be  cited  as  conflicting  with  the 
statement.  But  Arnold  was  a  highly  strung  neurotic,  and 
greatly  exhausted  at  the  time  (as  well  as  being  morbidly 
afraid  of  the  prospect  of  angina) ;  which  largely  explains 
the  fatal  result.  John  Hunter  often  fainted  from  agony 
in  his  attacks ;  but  twenty  years  elapsed  betwixt  his 
first  attack  and  the  fatal  seizure.  Indeed,  Hunter's 
was  a  typical  instance  of  true  angina  in  a  neurotic 
individual. 

Such  persons  manifest  local  arterial  spasms  in  the  form 
of  '  dead  hands  ;'  the  fingers  often  going  pallid  and  blood- 
less, and  feeling,  as  well  as  looking,  like  the  fingers  of  a 
corpse.  At  other  times  the  feet  go  deadly  cold.  And 
one  case  has  come  under  my  notice  where  the  pheno- 
mena seemed  to  point  to  spasmodic  contraction  of  the 
posterior  cerebral  arterial  area.  In  women,  at  or  about 
the  change  of  life,  '  hot  flushes  '  (as  they  are  termed) 
suffuse  the  neck  and  face.  There  is  acute  arteriole 
dilatation  seen  passing  like  a  wave  over  the  visible 
portions  of  the  person.*  The  vaso-motor  system  is  in 
a  state  of  irritability  evidently  in  such  persons. 

'"'  Whether  the  dilatation  of  the  cutaneous  arterioles  is  confined  to 
the  neck  and  head,  and  is  only  seen  there  as  visible  parts,  is  not  deter- 


MIDDLE  STAGE. 


93 


If  arteriole  spasm  be  excited  chronically  by  the  accumu- 
lation of  the  products  of  albumen-metamorphosis  in  the 
blood,  it  is  not  difficult  to  conceive  that  times  of  exacerba- 
tion should  occur  at  intervals.  In  all  probability  the 
immediate  excitement  of  the  spasm  in  the  hypertrophied 
muscular  wall  of  the  arterioles,  is  a  temporary  excess  of 
nitrogenized  waste  in  the  blood.  The  countenance  is 
blanched,  while  large  drops  of  sweat  roll  down  the  brow ; 
the  face  is  expressive  of  agony  ;  the  sufferer  is  incapable 
of  movement;  while  the  eye  mutely  begs  for  help.  In  a 
case  recently  in  Victoria  Park  Hospital,  the  man  looked 
like  one  led  out  for  execution,  and  realizing  the  bitter- 
ness of  death  itself.  (This  was  a  very  peculiar  case 
apparently  of  traumatic  origin,  and  not  specially  linked 
with  the  vaso-renal  change.  Otherwise,  it  was  a  genuine 
case  of  Angina  pectoris  vaso-motoria.)  The  radial  artery 
is  felt  tense  and  full ;  and  when  the  attack  passes  off,  the 
sufferer  voids  a  large  bulk  of  pale  urine  of  low  specific 
gravity — the  characteristic  urine  of  high  arterial  tension 
(Traube). 

The  pain  starts  about  the  mid-sternum,  and  radiates 
therefrom.  Eulenberg  thinks  it  follows  the  superior 
cardiac  nerves  and  the  four  upper  cervical,  also  the 
inferior  cardiac  nerve  and  the  lower  cervical  nerves 
existing  in  the  brachial  plexus.  The  pain  is  felt  like  a 
bolt  through  the  chest,  and  has  a  tendency  to  shoot  down 
the  left  ulnar  nerve  to  the  little  finger.  In  one  case  it 
also  went  out  at  the  ears  backwards.  Its  duration  varies 
from  seconds  to  minutes  ;  and  the  attack  can  now  be  cut 
short   by  such  remedial  agents   as  nitrite    of  amyl   and 

mined  yet.     Dieffenbach,  when  removing  a  tumour  from  the  pudenda 
of  a  lady,  saw  a  blush  (Schamrothe)  suffuse  the  genitalia. 


94  VASO-RENAL  CHANGE 

nitroglycerine,  which  dilate  the  peripheral  arterioles ; 
a  line  first  taken  by  Dr.  Brunton.  In  fatal  cases  the 
left  ventricle  is  found  flaccid  and  distended  with  blood ; 
the  heart  stopping  in  diastole,  or  abortive  systole.  In  one 
case,  where  the  patient  all  but  died,  a  condition  of  extreme 
dilatation  was  left  behind. 

The  neurotic  is  liable  to  angina  which  may  disappear 
under  appropriate  treatment  ;  or  proceed,  gathering  in 
intensity  as  years  roll  on,  as  was  the  case  with  John 
Hunter ;  who,  not  knowing  its  causation,  could  not  adopt 
any  rational  preventive  treatment.  Angina  pectoris  vaso- 
motoria is  an  exaggerated  spasm  of  the  thickened  arterioles, 
mostly  found  in  the  neurotic  group  of  lithsemic  persons ; 
and  comparatively  little  known  to  the  Norse  type  until 
an  advanced  'stage  is  reached.  When  the  heart-wall  is 
undermined  by  fatty  degeneration,  the  danger  to  life  is 
very  grave. 

Epistaxis. — With  the  condition  of  high  arterial  tension, 
haemorrhage  is  ever  probable.  Bleeding  at  the  nose  in 
early  years  is  a  matter  of  trifling  moment  usually,  and 
often  a  distinct  relief  to  the  child.  But  when  middle  age 
is  reached,  epistaxis  may  be  serious  in  itself,  and  require 
energetic  measures  for  its  arrest.  Beyond  that  there  lies 
its  prognostic  import.  In  my  own  experience  it  has  been 
associated  with  the  vaso-renal  change  ;  and  further  with 
cases  moving  on  from  bad  to  worse  at  a  comparatively 
rapid  rate.  An  old  physician  of  great  experience  informs 
me  that  it  has  not  unfrequently  been  the  termination  of 
gouty  persons  of  his  acquaintance. 

Atheroma. — Degeneration  of  the  arteries  commences  in 
a  growth  of  connective  tissue  which  lessens  the  elasticity 
of  the  arterial  wall..    The  term  we  use  for  such  change  in 


MIDDLE  STAGE.  95 

the  arterial  wall  is  atheroma.  It  occurs  locally,  as  at  the 
axilla  and  popliteal  spaces,  where  the  artery  is  frequently 
flexed ;  it  occurs  at  the  outside  curve  of  the  arch  of  the 
aorta,  which  receives  the  shock  of  the  ventricular  systole ; 
and  also  is  set  up  when  an  artery  is  exposed  to  pressure — 
thus  the  coronary  arteries  exposed  without  intermediary 
arteries  to  the  full  force  of  each  cardiac  systole,  are 
often  affected  more  seriously  than  other  arteries.  But  as 
a  widespread  change,  atheroma  is  produced  by  hyper- 
distension  (Ueberspannung)  of  the  arterial  wall.  It  is, 
indeed,  the  outcome  of  the  high  arterial  tension  set  up 
and  maintained  by  the  hypertrophy  of  the  muscular  wall 
of  the  arterioles  and  the  large  left  ventricle.  The  effect 
of  high  internal  pressure  is  to  start  up  a  growth  of  connec- 
tive tissue  in  the  wall  of  the  artery  which  lessens  its 
elasticity,  and  in  time  renders  it  brittle.  So  altered,  the 
artery  becomes  liable  to  rupture,  and  this  gives  us 
aneurysm  and  apoplexy  ;  two  diseases  which  are  certainly 
associated  closely  with  the  vaso-renal  change.  It  is  the 
growth  of  connective  tissue  in  the  coronary  arteries 
which,  at  a  later  stage,  works  the  structural  ruin  of  the 
large  heart.  As  pointed  out  in  Chapter  II.,  the  first 
physiological  departure  is  the  reversion  to  the  uric  acid 
formation  ;  while  the  great  anatomical  departure  is  the 
growth  of  connective  tissue— which  in  the  viscera  gives  us 
cirrhosis,  and  in  the  arterial  wall  atheroma. 

What  part  syphilis  plays  in  inclining  the  arterial  wall 
to  take  on  the  atheromatous  change,  is  a  matter  on  which, 
in  the  present  state  of  our  knowledge,  we  can  only  specu- 
late. Extending  observation  may  before  long  bring  its 
influence  to  light ;  but,  so  far,  it  remains  largely  hidden. 
One   can   even   already,    however,   feel    something   more 


96 


VA SO-RENAL  CHANGE. 


than  a  suspicion  that  syphilis  exercises  a  malign  influ- 
ence in  predisposing  the  arteries  to  the  atheromatous 
change. 

The  accompanying  woodcut  shows  the  changes  in  the 
arterial  wall  wrought  by  a  blending  of  syphilis  with  the 
vaso-renal  change.  By  comparing  this  with  Fig.  3,  p.  44, 
the  difference  will  at  once  be  seen.  In  Fig.  3  the  outer 
and  middle  coats  are  implicated  ;  while  in  this  section,  in 


Fig.  8.— Transverse  section  of  the  Small  Arteries  of  the  Kidney. 
Magnification,  300  diameters,  a.  Section  of  an  artery  from  a 
normal  healthy  human  kidney,  b.  Section  of  an  artery  with  all 
three  coats  thickened,  and  the  lumen  diminished.  The  specimen 
was  obtained  from  a  case  of  vaso-renal  change.  It  will  be  noted 
that  the  inner  coat  is  particularly  affected,  constituting  a  condition 
approaching  Endarteritis  obliterans.  Probably  this  thickening  of 
the  interior  coat  was  syphilitic  in  origin. 


addition,  there  can  be  seen  changes  in  the  inner  coat.  It 
is  a  small  vessel,  and  tells  us  much  as  to  how  the  vessels 
of  the  coronary  circulation  undergo  the  atheromatous 
change  ;  and  especially  that  thickening  of  the  tunica  intima 
which  works  the  ruin  of  the  heart-wall.  .  Beyond  the 
growth  of  the  connective  tissue — the  essential  change  in 
this  morbid  process — we  find  hypertrophy  of  the  muscular 
fibre  of  the  vascular  system.  And  in  the  end,  the  growth 
of  the  connective  tissue  ruins  its  muscular  ally. 


MIDDLE  STAGE.  97 

Aneurysm, — When  the  arterial  wall  is  brittle,  and  the 
internal  pressure  upon  it  abnormally  high,  it  is  liable  to 
rupture,  partial  or  complete.  A  blow  at  the  time  of 
arterial  distension  may  cause  this ;  and  a  fall  in  the 
hunting-field  is  not  unfrequently  its  immediate  antecedent. 
At  other  times  the  weakened  wall  yields,  and  gives  us 
either  the  fusiform  or  the  sacculated  aneurysm,  without 
rupture  of  any  of  the  arterial  coats.  Effort  certainly  is 
productive  of  aneurysm ;  and  often  causes  an  aneurysm  in 
the  atheromatous  ascending  aorta.  A  typical  instance  of 
this  occurred  to  a  colour-sergeant  who  was  long  under 
my  care  at  the  West  London  Hospital  some  years  ago. 
He  was  an  active  man  of  over  forty,  with  a  large  heart 
and  hardening  arteries.  Being  called  out  to  take  part  in 
some  autumn  manoeuvres,  he  made  vigorous  efforts  to 
keep  up  with  his  younger  comrades.  The  consequence 
was  an  aneurysm  of  the  ascending  aorta.  At  other  times 
an  atheromatous  patch  undergoes  fatty  degeneration;  and, 
the  softened  material  being  washed  off  in  the  blood- 
current,  an  ulcer  is  left,  and  an  aneurysm  forms.  At 
other  times  the  ulcer  heals,  as  shown  by  the  cicatrices 
formed — the  '  scars  of  Dittrich.'  The  blood  may  find  its 
way  into  the  tissues  of  the  artery,  and  plough  its  way 
through  in  time.  Such  a  dissecting  aneurysm,  com- 
mencing in  an  ulcer  in  the  arterial  wall  about  two  inches 
up  the  aorta,  and  burrowing  away  for  some  distance, 
came  under  my  notice  in  a  pallid  woman  of  middle  age, 
who  died  suddenly,  when  I  was  connected  with  the 
Leeds  Public  Dispensary.  She  had  complained  of  vague 
pains  in  her  chest,  and  had  been  confined  to  her  bed  with 
illness.  She  was  improving,  and  was  trying  to  dress  her- 
self,  when  the  effort  produced  the  final  rupture  of  the 

7 


98  VASO-RENAL  CHANGE. 

aneurysm,  with  effusion  into  the  pericardium.    In  this  case 
the  blood  burrowed  back  towards  the  heart. 

Effort,  by   temporarily  raising   the   blood-pressure,    is 
distinctly  connected  with    aneurysms.     But  in   my  per- 
sonal experience    aneurysms    have    mainly   occurred    in 
comparatively  young  men  who  have  had  syphilis,  and  in 
older   men    in    connection   with   vaso-renal   change.     In 
connection   with   the   last,   it    has   not   been   uncommon 
to  find  aortic  dilatation,  with  insufficiency  of  the  aortic 
valves.     When  we  remember  the  distending  force  of  the 
huge  ventricle  which  goes  with  this  valvular  lesion,  giving 
at  once  greater  power  and  a  larger  bulk  of  blood,  it  is  not 
difficult  to  comprehend  how  dilatation  of  the  aortic  arch 
is  produced.     In  one  such  case,  where  the  arterial  change 
(general  dilatation  of  the  aortic  arch,  with  bulging  at  the 
roots  of  the  carotid  arteries  on  both  sides)  was  of  recent 
origin,  my  efforts  were  bent  towards  lowering  the  blood- 
pressure  by  poor  fare,  and  sulphate  of  soda  to  sweep  all 
waste  matter  out  of  the  blood,  in  order  to  see  what  the 
elasticity  of  the  arterial  wall  could    accomplish.     Great 
success  was  thus  attained,  and  the  bulging  all  but  dis- 
appeared.    At  this  point    the   patient's   wife   interfered. 
She    did    not    deny  the   general    improvement — the    dis- 
appearance of  the  cough  (from  pressure  on  the  recurrent 
laryngeal  nerve),  or  the  diminution  of  the  bulging  in  the 
neck.     But  she  had  made  up  her  mind  to  feed  him  up  ; 
and  left  my  house  fully  determined  to  take  her  own  way, 
despite  sundry  and  divers  warnings  of  the  risks  she  was 
incurring  in   so   doing.     In  a  month  or  two  the  patient 
died  with  a  huge  aneurysm  under  the  left  clavicle.     She 
succeeded  in  bringing  about  the  very  danger  which  had 
been  pointed  out  to  her,  and  against  which  she  had  been 


MIDDLE  STAGE.  99 

warned.     The  history  of  the  case  is  instructive,  with  both 
a  positive  and  a  negative  lesson  in  it. 

Apoplexy. — Apoplexy — true,  genuine  rupture  of  an  inter- 
cranial  artery,  as  compared  to  embolic  closure  of  a  vessel, 
or  softening,  or  other  cause  of  obliteration  of  the  functions 
•of  the  brain  more  or  less  complete — is  found  especially  in 
persons  in  whom  the  vaso-renal  change  is  established.  It 
occurs  equally  alike  in  the  small,  slight  neurotic  and  the 
bulky  Norseman  ;  who  is  supposed  to  be  its  victim  par 
excellence.  In  the  deadhouse  it  is  quite  common  to  see  the 
internal  caroiid  arteries  looking  like  quills.  In  such  cases 
there  is  also  a  large  left  ventricle,  with  some — more  or 
less  —change  in  the  kidneys.  Often  the  person  has  died 
of  aneurysm.  The  atheromatous  change  goes  on  very 
markedly  in  the  arteries  within  the  skull,  whose  blood- 
current  is  swift.  Such  apoplexy  is  common  when  a 
sudden  spell  of  cold  sets  in  :  the  contraction  of  the  vessels 
of  the  cutaneous  area  raises  the  blood-pressure  in  the 
arteries  elsewhere,  and  then  a  brittle  artery  of  the  brain 
cracks.  This  addition  to  the  internal  pressure  is  the  last 
straw  which  breaks  the  camel's  back.  That  the  blood- 
pressure  is  raised  is  evidenced  by  the  increased  bulk  of 
urine  experienced  at  such  incomes  of  cold.  The  obituary 
column  of  the  Times  tells  of  the  increase  in  the  number  of 
aged  persons  who  die  in  sudden  cold-snaps.  Of  course, 
they  do  not  all  die  of  apoplexy ;  some  die  of  angina,  or 
aneurysm,  or  sink  from  heart-failure,  especially  where  the 
heart-wall  is  weakened  by  fatty  degeneration.  Still,  a 
distinct  proportion  do  die  of  cerebral  apoplexy. 

Very  frequently  small  miliary  aneurysms  of  the  cerebral 
arteries  form  the  seat  of  rupture.  In  the  following  illustra- 
tion miliary  aneurysms  of  this  kind  are  distinctly  seen. 

7—2 


ioo  VA SO-RENAL  CHANGE. 

When  such  alterations  of  the  arterial  walls  are  in 
existence,  any  rise  in  the  blood-pressure  generally,  will 
tend  to  rupture  the  weakened  wall.  Dr.  Hilton  Fagge 
has  given  a  good  account  of  such  miliar}'  aneurysms  in  his 
'  Practice  of  Physic;'  and  pointed  out  how  they  are  linked 
with  chronic  renal  disease.  Apoplexy  from  rupture  of  the 
sac  of  these  small  aneurysms  is  readily  produced  by 
anything  putting  strain  upon  the  bloodvessels — effort, 
straining  at  stool,  vomiting,  or  arterial  spasm  (angina 
pectoris  vaso-motoria). 


ni'ftoit. 

Fig.  9. — Miliary  Aneurysms,  natural  size,  obtained  from  a  case  of  apo- 
plexy, by  washing  away  the  brain  substance  from  the  vessels  of  the 
basal  ganglia. ,  The  patient  had  a  large  heart  and  contracted  kidneys. 

In  ordinary  apoplexy  a  blood-clot  forms  around  the 
orifice.  The  artery  keeps  pumping  away  into  the  clot, 
acting  like  the  hydraulic  ram  ;  and  the  waxing  clot 
squeezes  the  soft  brain-tissues,  and  extinguishes  their 
function.  Commonly,  the  motor-centres  along  the  fissure 
of  Rolando  are,  from  their  position  and  the  seat  of  the 
rupture,  the  first  to  be  pressed  upon.  Sometimes  the  clot 
is  so  small  that  these  areas  alone  are  compressed  till  their 
function  is  lost.  As  soon  as  the  clot  ceases  to  grow,  and 
then  becomes  less  by  absorption,  the  diminishing  pressure 
permits  of  the  compressed  portion  of  brain  regaining  its 
function  more  or  less  completely.      At   other  times  the 


MIDDLE  STAGE.  lor 

clot  waxes,  as  the  blood,  driven  into  the  carotids  by  a 
large  left  ventricle,  swells  the  volume  of  the  clot.  The 
skull  is  unyielding,  and  the  imprisoned  textures  suffer 
from  the  presence  of  the  intruder.  This  case  is  like  that 
of  a  boat  filled  with  passengers,  when  the  crew  want  to 
join  them,  as  in  a  shipwreck,  for  instance.  They  either 
throw  an  equal  number  of  the  previous  occupants  over- 
board, or  sink  the  boat — which  can  only  hold  so  many. 
So  the  blood-clot  waxes,  ploughing  its  way  through  the 
soft  tissues,  and  compressing  where  it  does  not  destroy. 
At  last  some  interference  in  the  respiration  tells  that  the 
pressure  is  extending  to  the  medulla  oblongata,  and  that 
the  danger  to  life  has  become  imminent.  The  high 
internal  pressure  within  the  arteries  is  telling  with  fatal 
effect.  The  large  ventricle  is  driving  on  the  blood,  and 
enlarging  the  blood-clot.  The  larger  the  blood-clot,  the 
greater  the  pressure  on  the  soft  cerebral  structures.  The 
sensory  area  has  had  its  life  squeezed  out  of  it ;  the  motor 
area  is  paralyzed.  The  intruder  ploughs  towards  the 
occiput  and  the  base  of  the  brain,  the  tentorium  cerebelli 
giving  it  direction.  Soon  the  fell  pressure  is  experienced 
by  the  noeud  vital;  and  when  the  medulla  is  sufficiently 
compressed,  life  closes. 

No  wonder  that  Rokitanski  found  the  apoplexy  which 
is  suddenly  fatal  (foudroyante)  to  be  linked  with  a  large 
left  ventricle.  It  is  just  the  large  left  ventricle,  together 
with  the  hypertrophied  muscular  wall  of  the  arterioles, 
giving  high  arterial  tension,  which  keeps  up  the  growth 
of  the  clot,  and  prevents  the  waxing  pressure  from  arrest- 
ing the  haemorrhage.  We  can  readily  understand  why 
apoplexy  is  a  common  cause  of  death  in  persons  under- 
going vaso-renal  change. 


102  V  A  SO-RENAL  CHANGE. 

Epistaxis. — Another  matter  linked  with  the  changes  in 
the  vascular  system,  and  associated  with  high  arterial 
tension,  is  that  of  epistaxis.  Epistaxis  in  persons  advanced 
in  years  is  a  phenomenon  of  bad  prognostic  import ;  and 
one  which  one  learns  by  experience  to  dislike.  In  the  cises 
which  have  come  under  my  own  notice,  it  has  occurred 
in  persons  undergoing  the  vaso-renal  change;  and  has  been 
the  harbinger  of  disaster.  In  one  case  it  was  accom- 
panied by  such  extensive  mischief  in  the  retina,  that  total 
loss  of  vision  was  the  consequence.  One  medical  man  of 
large  experience  informs  me  that  bleeding  to  death  from 
the  nose  has  been  the  actual  end  of  a  number  of  gouty 
persons  of  his  acquaintance. 

Gangrene. — The  change  which  goes  on  in  the  arterial 
wall  has  a  high  interest  for  the  surgeon.  Sometimes 
lime  salts  are  deposited  in  the  connective  tissue  of 
atheromatous  arteries,  which  renders  them  more  brittle 
still ;  so  that  if  there  arises  any  occasion  for  applying  a 
ligature  to  them,  they  break  down,  and  cause  a  great  deal 
of  trouble.  In  some  cases  the  arteries  can  be  felt  like 
the  stems  of  long  clay  tobacco  pipes.  In  other  instances 
the  atheromatous  arteries  undergo  a  fatty  degeneration, 
and  are  thick  and  comparatively  soft.  The  different  form 
assumed  by  the  atheromatous  artery  can  often  be  readily 
detected  in  the  temporal  arteries  meandering  under  the 
skin.  Sometimes  along  with  general  atheromatous  change 
there  is  a  marked  change  at  certain  points,  termed  by 
surgeons  '  obstructive  arteritis,'  which  occludes  the  vessel; 
and  causes  the  parts  beyond  to  die,  giving  gangrene,  or 
mortification. 

Changes  in  the  Kidney. — The  essential  change  in  the 
kidnev  is  that  of  a  chronic  and  usually  slow  progressive 


MIDDLE  STAGE.  103 

growth  of  connective  tissue ;  which  destroys  the  true  renal 
structures.  In  order  to  make  the  morbid  change  perfectly 
clear  to  readers  who  may  not  have  had  recent  opportunities 
for  studying  pathology,  and  who  have  been  engaged  in  active 
practice,  Dr.  Mott  has  furnished  to  me  some  illustrations, 
which  will  greatly  facilitate  a  good  comprehension  of  what 
exists  normally;  as  well  as  illustrative  sections  of  kidneys 
the  seat  of  this  interstitial  nephritis.* 


Fig.  10.— Section  of  the  Cortex  of  a  Healthy  Human  Kidney,  obtained 
from  a  boy  killed  by  an  accident. — The  glomeruli  are  seen  sur- 
rounded by  the  uriniferous  tubules.  It  will  be  noticed  that  the 
capsule  is  thin,  and  the  amount  of  connective  tissue  between  the 
tubules  is  so  small  as  to  be  inappreciable;  thus  presenting  a  striking 
contra-t  to  the  sections  of  kidney  indicating  the  various  stages  of 
interstitial  nephritis.     Magnification,  1 50  diameters. 


In  Fig.  10  we  see  a  section  of  the  cortex  of  the  kidney, 
and  see  there  bloodvessels  and  urinary  tubules  with  the 
glomeruli  all  massed  together;  with  a  minimum  of  packing 
material,  or  connective  tissue  holding  all  together.  Then 
in  the  following  diagrammatic  sketch  is  shown  the 
functional  apparatus  of  the  kidney. 

*  They  are  drawn  from  specimens  prepared  by  himself. 


104 


VA  SO-RENA  L  CHA  NGE. 


Fig.  n.— Diagrammatic  Representation  of  a  Uriniferous  Tubule,  and 
the  Vascular  Supply  of  the  Cortex  of  the  Kidney.—  a,  afferent 
arteriole  going  to  glomerulus,  and  given  off  from  b,  the  interlobular 
branch,  which  runs  straight  up  into  the  cortex  from  the  arch  c. 
The  vasa-recta,  d,  are  also  given  off  from  these  arches,  which  are 
situated  at  the  base  of  the  pyramids.  The  efferent  vessel,  e,  instead 
of  opening  into  a  larger  vessel,  breaks  up  into  a  plexus  around 
the  uriniferous  tubule,  particularly  the    convoluted   portion.     The 


MIDDLE  STAGE. 


105 


Fig.  12. — Section  of  the  Cortex  of  a  Healthy  Human  Kidney,  showing 
a  Glomerulus,  with  Afferent  Arteriole  given  off  from  an  Interlobular 
Artery. — The  convoluted  tuft  in  which  the  afferent  arteriole  ter- 
minates, is  covered  by  epithelium,  of  which  the  nuclei  are  distinctly 
seen.  The.  delicate  capsule  is  seen  surrounding  the  vascular  tuft. 
Around  the  glomerulus  are  the  uriniferous  tubules,  mostly  from  the 
convoluted  portion.  It  will  be  noticed  how  little  connective  tissue 
there  is  around  the  glomerulus  and  its  afferent  vessel.  Magnif  ca- 
tion, 300  diameters. 

A  small  artery  is  seen  giving  off  one  branch  to  the 
cortex,  and  another  towards  the  pyramidal  or  tubular 
portion  of  the  kidney.  The  cortical  twig  gives  off  still 
smaller  twigs  ending  in  a  tuft. 


uriniferous  tubule,  _/",  is  seen  to  take  a  very  winding  and  circuitous 
course  before  opening  by  the  collecting  tubule  into  the  excretory 
duct,  g.  The  portion  of  the  uriniferous  tubule,  which  is  marked  by 
fine  dots  is  lined  by  a  striated  epithelium,  and  represents  the  part 
engaged  in  the  secretion  or  elimination  of  the  urine  ;  while  it  is 
believed  the  water  with  some  of  the  salts  filtered  out  of  the 
glomerulus,  a,  into  the  capsule,  washes  out  the  urine  as  it  courses 
down  the  tube.  Finally  the  solution  of  urine  and  salts,  as  indicated 
by  the  arrows,  passes  into  the  collecting  tube,  g.  The  line  which 
separates  the  cortex  from  the  medullary  portion  may  be  roughly 
considered  as  existing  at  the  position  of  the  vascular  arch,  c ; 
therefore  it  will  be  seen  that  the  cortex  is  concerned  with  all  the 
essential  functions  of  the  urinary  secretion. 


106  VASO-RENAL  CHANGE. 

In  Fig.  11  this  tuft  is  still  more  highly  magnified.  The 
tuft  occupies  a  cavity,  and  over  it  and  the  wall  of  the 
cavity  a  layer  of  epithelium  is  reflected,  much  after  the 
manner  of  the  pericordium.  Beyond  this  tuft  is  a  larger 
plexus  of  vessels,  and  the  obstruction  offered  by  this 
venous  network  causes  a  high  blood-pressure  in  the 
glomerulus  itself,  and  exudation  of  fluid — the  urine.  The 
urinary  tubule  is  coiled  up  among  the  venous  network, 
from  which  it  emerges  and  pursues  a  tortuous  course, 
doubling  on  itself  as  seen  in  the  diagrammatic  sketch. 
Various  theories  have  been  put  forward  as  to  what  goes  on 
in  these  long  convoluted  conduits.  Whether  the  urine  is 
highly  aqueous  at  the  start,  and  collects  salts  of  various 
kinds,  and  products  of  albumen-metamorphosis  in  its 
course,  or  vice  versa,  is  a  matter  which  scarcely  concerns 
us  here.  But  by  the  time  it  has  reached  the  straight 
conduits  by  which  it  debouches  '  into  the  pelvis  of  the 
kidney  it  has  become  the  fluid  with  which  we  are 
familiar. 

The  urine  varies  considerably  as  to  its  specific  gravity, 
its  colour,  and  its  reaction  even  in  health.  In  the  vaso- 
renal change  these  modifications  are  even  more  pro- 
nounced ;  and  one  day  it  is  a  dilute  urine,  pale  in  colour, 
of  low  specific  gravity,  and  copious.  Another  day  it  is 
high-coloured,  dense,  scanty,  and  of  high  specific  gravity. 
Bearing  these  facts  in  mind,  it  is  obvious  that  any  exami- 
nation of  the  urine  must  extend  over  a  considerable  period 
of  time  to  be  of  any  utility.  The  bulk  passed  in  each 
twenty-four  hours  must  be  collected ;  and  a  sample  be 
taken  from  the  whole.  The  specimen  of  one  day  must 
be  contrasted  with  that  of  several  other  days,  with  intervals 
between,  to  give  any  correct,  or  fairly  accurate  conception 


MIDDLE  STAGE.  107 

of  the  urine.  The  dietary,  the  conditions  of  life,  of 
exercise,  of  quietude  or  effort,  must  be  calculated  with 
each  specimen ;  in  order  to  arrive  at  any  conclusion  worth 
the  having,  or  the  holding. 

When  the  comparatively  insoluble  uric  acid  is  constantly 
passing  through  renal  structures  constructed  to  excrete 
the  highly  soluble  urea,  it  irritates  the  tissues ;  and  a 
growth  of  connective  tissue  is  started,  here  and  there, 
throughout  the  kidneys. 

When  Dr.  Bright  first  drew  attention  to  the  changes  in 
the  kidneys  in  the  disease  which  has  since  borne  his  name, 
he  caught  sight  of  the  final  changes  of  the  morbid  process 
which  is  being  sketched  out  in  these  pages.  Chronic 
Bright's  Disease  was  then  an  affection  of  the  kidneys,  and 
as  such  is  classed  amongst  diseases  of  the  kidney  in  the 
'  Nomenclature  of  Disease,'  published  by  the  Royal  Col- 
lege of  Physicians  of  London ;  *  and  followed  accordingly 
by  writers  of  treatises  and  text-books.  Yet  Professor  Geo. 
Johnson,  F.R.S.,  long  years  ago  pointed  and  emphasized 
the  matter  in  italics  :  '  Renal  degeneration  is  a  consequence  of 
the  long-continued  elimination  of  products  of  faidty  digestion 
through  the  kidneys.''  Such  an  affection  surely  cannot  be  a 
primary  kidney-change ;  but  some  derangement  in  the 
organs  of  assimilation  and  of  albumen-metamorphosis  ! 
Garrod  says  of  gout  and  the  changes  in  the  urinary 
organs :  '  My  own  observations  lead  me  to  think  that 
gouty  inflammation  is  often  set  up  in  the  interior  structure 
of  the  kidney,  accompanied  with  deposits,  not  merely 
within  the  tubuli  uriniferi,  but  in  the  -fibrous  tissue  itself. 
It  may  be  that  the  structure,  from  the  circumstances  in 
which  it  is  placed,  being  in  constant  contact  with  a  fluid 
*  And  is  so  classed  to  the  present  day. 


10S  VA SO-RENAL  CHANGE. 

having  an  acid  reaction,  is  selected  as  the  early  seat  of 
gouty  deposition ;  that  it  is  frequently  so  chosen,  proof 
has  been  afforded  in  the  fact  that  white  points  of  urate  of 
soda  were  observed,  with  few  exceptions,  when  these 
organs  are  examined.'  Surely,  in  the  name  of  reason  the 
uric  acid  formation  must  have  preceded  the  deposition  of 
urates ;  whether  in  the  kidney,  or  in  the  articulations  ? 

So  long,  of  course,  as  the  morbid  change  designated 
'  Chronic  Bright's  Disease  '  is  officially  classified  among 
'  Diseases  of  the  Kidney,'  so  long  must  it  have  a  mis- 
leading influence  ;  and  obscure  the  actual  clinical  facts. 

That  the  constant  presence  oi  uric  acid  in  considerable 
quantity  in  organs  constructed  to  cast  out  the  soluble 
urea,  will  excite  tissue-changes  in  them  in  time,  is  not  a 
matter  very  difficult  to  comprehend. 

What  is  the  tissue-change  which  goes  on  in  the 
kidney?  It  is  seen  in  a  subsequent  engraving,  p.  112. 
This  is  what  Dr.  Dickenson  says  :  '  The  change 
begins  in  disproportioned  growth,  somewhat  of  a  rank 
luxuriance  in  the  fibroid  tissue  with  which  the  arterial 
channels  are  uniformly  fringed.  Hypertrophy  of  this  part 
leads  to  atrophy  of  all  the  rest.  Creeping  along  the 
arterial  lines  with  slow  and  hesitating  steps,  involving  the 
organ  not  all  at  once,  but  little  by  little,  the  disease  makes 
itself  felt  not  suddenly,  but  with  so  gradual  departure 
from  health,  that  its  date  is  usually  undeterminable,  and 
its  existence  unsuspected  until  it  has  reached  an  advanced 
stage.'  No  statement  could  be  more  explicit  than  this. 
There  is  a  stage  anterior  to  obvious  injury  to  the  kidney. 
A  certain  destruction  of  kidney-tissues  goes  on  before  any 
actual  incompetence  in  the  organ  is  reached.  We  all 
have  some  '  spare  '  kidney  as  we  have  '  spare  '  lung.     It  is 


MIDDLE  STAGE.  109 

only  when  the  limit  compatible  with  functional  capacity 
is  passed,  that  the  kidney  mischief  forces  itself  upon  the 
attention.  How  many  years  may  elapse  before  the  essen- 
tial amount  of  kidney  is  involved  may  not  be  affirmed. 
So  long  only  as  the  '  spare  '  kidney  alone  is  being  de- 
stroyed, the  kidney  phenomena  are  latent.  As  to  the  rate 
of  progress  and  how  it  is  brought  about,  Sir  Wm.  Roberts, 
M.D.,  F.R.S.,  delivers  himself  thus  :  '  The  disease  usually 
pursues  an  interrupted  course.  It  is  subject  to  exacer- 
bations from  time  to  time,  with  intervals  of  quiescence. 
The  exacerbations  are  generally  occasioned  by  exposure 
to  cold,  or  some  imprudence  in  diet  or  regimen ;  some- 
times no  cause  can  be  assigned  for  their  occurrence.' 
Again  :  '  After  each  exacerbation  it  is  commonly  pretty 
evident  that  the  disease  has  taken  a  step  in  advance,  and 
assumed  a  fuller  development  ;  and  that  probably  an 
additional  portion  of  the  kidney  hitherto  spared,  or  only 
slightly  affected,  has  been  disabled.'  Virchow  thinks  that 
acute  gout  may  manifest  itself  in  one  form  as  acute 
nephritis. 

Thus  we  see  that  it  is  not  an  acute  invasion  (as  occurs 
in  some  cases  which  can  fairly  enough  be  still  termed 
'  Bright's  Disease ')  ;  but  a  silent,  insidious,  stealthy  pro- 
cess of  gradual  ruin  of  the  kidney.  Certainly,  in  such  a 
condition  of  chronic  interstitial  nephritis  comparatively 
slighter  causes  will  occasion  acute  nephritis  than  are 
required  with  persons  whose  kidneys  are  perfectly  sound. 
But  it  is  rather  a  difference  of  degree  than  anything 
essential.  Roberts,  speaking  of  such  cases,  writes  :  '  The 
disease  may  lie  concealed  for  an  undetermined  period,  and 
then  reveal  itself  after  exposure  to  cold,  or  a  fit  of  intoxi- 
cation in  the  guise  of  an  acute  attack— with  rapid  general 


no  VA  SO-RENAL  CHANGE. 

anasarca,  and  scanty  sanguineous  urine.'  Such,  to  the 
best  of  my  belief — so  far  as  the  history  of  the  causes  can 
be  traced  in  Dr.  Bright's  notes — were  the  cases  originally 
recorded  by  him  in  his  '  Medical  Reports.'  They  seem  to 
have  been  cases  of  slow  insidious  interstitial  nephritis 
with  acute  mischief  engrafted  thereupon.  Of  course  when 
an  observation  is  first  made,  the  prominent  phenomena 
are  those  which  immediately  precede  death.  And  that 
excellent  observer,  when  testing  the  albuminous  urine  in 
the  primitive  manner  of  a  spoon  and  a  candle,  and  putting 
two  and  two  together  in  the  association  of  the  dropsy  with 
the  albuminuria,  and  diagnosing  kidney  mischief,  could 
scarcely  have  dreamed  of  the  long  vista  of  anterior  history 
to  which  he  was  then  opening  the  portal.  He  stood  at 
the  threshold,  and  after  him  one  observer  after  another 
has  pushed  in  at  the  opening  he  made,  until  the  unknown 
country  has  been  explored  ;  and  indeed  is  now  being  to 
some  extent  surveyed.  Further  and  further  advances 
have  been  made,  until  now  we  seem  within  a  measurable 
distance  of  its  confines ;  and  see  in  the  reversion  of  the 
liver  to  the  formation  of  the  primitive  urinary  stuffs  the 
first  departure  from  health.  Not  only  that,  but  we  are 
beginning  to  know  that  excessive  indulgence  in  animal 
food  is  not  the  sole  cause  of  the  uric  acid  formation  ;  and 
that  it  may  be  the  consequence  of  a  congenitally  feeble 
liver ;  and,  further  than  that,  we  are  beginning  to  have 
some  glimmerings  as  to  how  far  mental  causes  play  a  part 
in  this  liver-degeneracy.  It  is  a  far  cry  to  Lochawe  ! 
And  an  immense  morbid  area  lies  betwixt  Dr.  Bright 
standing  on  the  portal  with  his  spoonful  of  urine  and  a 
candle  peering  into  the  unknown  land;  and  the  present 
observer  already  noting  that  vaso-renal  change  may  fairly 


MIDDLE  STAGE.  in 

be  regarded  to  a  large  extent  as  an  outcome  of  modern 
civilization,  and  the  demands  now  made  upon  the  nervous 
system. 

One  observer  after  another  has  pushed  the  inquiry  back 
from  its  finish  to  its  starting-point — or  what,  at  least  to 
present  vision,  seems  its  commencement.  Where  it  will 
ultimately  be  found  to  begin,  however,  may  scarcely  be 
affirmed  positively  ;  but  in  excessive  demand  upon  the 
brain,  and  the  subtle  associations  existing  between  the 
sensorium  as  the  organ  of  mind  and  the  glandular  appara- 
tus of  organic  life,  one  can  honestly  believe,  if  nothing 
more,  that  one  can  already  see  dimly,  and  as  through 
a  glass  darkly,  the  first  beginnings. 

Commencing  with  different  minute  foci,  tiny  patches  of 


SS&ff. 


Fig.  13.— Section  of  Cortex  of  Kidney,  showing  Early  Stage  of  Inter- 
stitial Nephritis  :  commencing  Fibrous  Overgrowth  around  the 
Capsule  of  the  Glomerulus.— a,  small  interlobular  artery  giving  ofif 
afferent  branch  to  the  glomerulus  ;  there  is,  apparently,  an  increase 
of  the  muscular  fibres  of  the  vessel.  The  vascular  tuft  is  shrunken, 
and  there  are  numerous  leucocytes  obscuring  the  epithelial  covering, 
and  also  lying  within  the  capsule  ;  and  around  the  capsule  and  small 
artery  there  is  an  increase  of  fibrous  tissue.  Magnification,  350 
diameters. 

soft  connective  tissue,  mainly  in  the  cortical  portion  of 
the    kidney,   each    holding   glomerulus,    bloodvessel    and 


ii2  VA SO-RENAL  CHANGE. 

tubule  in  its  remorseless  grip,*  as  it  contracts  and 
hardens,  it  makes  the  part  as  functionally  useless  as  if  it 
were  a  piece  of  gristle.  This  is  clearly  seen  in  the  Fig.  2, 
which  is  repeated  here.  While  in  its  contraction  the 
new  growth  has  dragged  down  the  surface  of  the  kidney 
cortex,    and  glueing  it  by  adhesive    inflammation  to  the 


Fig.  14. — Section  of  the  Cortex  of  an  Advanced  Granular  Contracted 
Kidney. — The  capsule,  a,  is  thickened,  and  elevations  and  depressions 
are  seen,  the  latter  corresponding  to  the  situation  of  the  glomeruli, 
around  which  the  fibrous  tissue,  fi,  is  more  abundant,  c,  Glomeruli ; 
d,  vessel  with  thickened  walls  ;  e,  small  cyst  forming  ;  f,  tubules, 
some  atrophied,     g,  capsule.     Magnifications,  80  diameters. 

capsule,  brought  that  down  with  it;  producing  an  uneven 
surface  and  an  adherent  capsule,  from  whence  the  term 
'  granular  kidney'  took  its  origin.  In  Fig.  15  we  see  a  more 
advanced  condition,  a  little  deeper  down  in  the  structure 
of  the  kidney.  We  see  a  patch  of  the  overgrowth  of 
connective  tissue  holding  an  atrophied  tubule  in  its 
clutch.     We  see  a  glomerulus  destroyed  as  to  all  func- 

5  If  the  reader  will  compare  this  with  the  Fig.  12  at  p.  105  he  will 
see  the  difference,  and  see  the  glomerulus  already  shrinking. 


MIDDLE  STAGE. 


"3 


tional  life.     We  see  an  artery  with  its  thickened  wall,  and 
at  the  top  a  tubule  choked  with  colloid  matter ;   while 


jf.w.imit. 


Fig.  15. — Section  of  the  Cortex  of  a  Granular  Contracted  Kidney  in 
an  Advanced  Stage  of  Interstitial  Fibrous  Overgrowth.  Magnifica- 
tion, 250  diameters.—  a  represents  a  glomerulus  considerably  con- 
tracted, and  with  a  thickened  fibrous  capsule  ;  b,  a  tube  filled  with 
a  colloidal  substance  ;  c,  an  artery  with  its  walls  thickened  ;  d,  a 
uriniferous  tubule  undergoing  conversion  into  a  small  cyst.  The 
remainder  of  the  section  is  occupied  by  a  nucleated  fibrous  tissue 
surrounding  atrophied  tubules. 

at  the  bottom  we  see  a  cyst  formed  from  a  portion  of 
occluded  tubule.  The  engraving  gives  a  very  clear  im- 
pression of  the  process  of  cirrhosis,  which  gradually  and 
stealthily  spreads  throughout  the  organ.  Drs.  Da  Costa 
and  Longsreth  have  shown  that  this  cirrhosis  involves 
the  nervous  ganglia  of  the  kidney  like  the  rest  of  the 
organ.  It  is  an  invader  which  establishes  itself  amidst 
the  tissue-aborigines  at  their  expense, — like  the  Tartar 
Turk  on  the  Balkan  peninsula ;  and  with  precisely  the 


H4  V A  SO-RENAL  CHANGE. 

same  disastrous  results,  viz.,   extermination   of  the   resi- 
dents. 

So  long  as  enough  of  sound  kidney  remains  for  blood- 
depuration  life  is  maintained  ;  when  the  limit  is  reached 
then  comes  uraemia,  and  either  coma  or  convulsions  ;  or 
some  secondary  inflammation  putting  an  end  to  life. 
Sometimes,  no  doubt,  in  less  advanced  cases,  the  inflam- 
mation is  survived ;  and  possibly,  or  even  probably, 
exercises  a  depurative  effect.  But,  as  the  limit  of  kidney 
destruction  is  reached,  life  is  threatened  from  other  out- 
comes of  vaso-renal  change,  as  angina,  or  apoplexy ;  for 
there  can  exist  no  doubt  that  apoplexy  and  aneurysm  are 
both  at  times  occasioned  by  vaso-motor  spasm  started  by 
imperfectly  depurated  blood.  Or  dropsy  supervenes  and 
wears  the  patient  out.  Or  maybe  it  is  diarrhoea  which 
closes  the  scene.  (Not  unfrequently,  however,-  ursemic 
diarrhoea  is  the  salvation  of  the  case.)  Or,  in  a  smaller 
number  of  cases,  vomiting  of  intractable  character —the 
vomited  fluid  readily  undergoing  ammoniacal  decomposi- 
tion— is  the  immediate  cause  of  death. 

But  such  a  widespread  morbid  change  gives  an  almost 
endless  variety  of  manifestations.  In  some  cases  the 
kidneys  soon  draw  attention  to  them  ;  while  in  other 
cases  the  patients  live  to  the  end — burn  down  to  their 
sockets — without  the  kidney  ever  attracting  notice ;  and 
the  changes  in  it  all  along  are  quite  latent.  The  kidney 
is  not  the  disease  par  excellence;  but  only  an  important 
portion  of  it.  Latent  or  obvious,  the  kidney  plays  a 
momentous  part,  as  imperfect  blood-depuration  is  the 
provoking  cause  of  evil  all  along  the  line,  from  beginning 
to  end.  It  is  possible  to  regard  the  kidney  as  often  a 
sort  of  martyr;  which  perishes  itself  in  saving  the  rest  of 


MIDDLE  STAGE.  115 

the  tissues.  The  only  objection  to  such  a  simile  is  that 
intelligence  on  the  part  of  the  tissues  has  figured  too 
largely  in  the  inquiry  into  the  vaso-renal  change.  It 
lurked  in  Johnson's  '  stop-cock  '  theory  of  arterial  spasm  ; 
and  in  compensatory  hypertrophy  of  the  heart  to  over- 
come obstruction.  Nature,  no  doubt,  has  conservative 
and  preservative  actions  in  the  organism  (which  is  self- 
preservative  to  a  very  considerable  extent) — albeit  a  losing 
fight.  It  is  impossible  to  escape  from  a  haunting  im- 
pression that  the  rise  in  arterial  tension  with  large  bulk 
of  urine  has  some  connection  with  the  insolubility  of  uric 
acid. 

As  to  the  appearance  presented  by  granular  kidneys 
in  consequence  of  the  interstitial  growth  of  connective 
tissue  in  them,  it  is  well  seen  in  the  accompanying 
drawing,  taken  from  Dr.  Bright's  beautiful  plates.  It 
is  a  typical  kidney;  and,  as  it  appears  in  his  book,  pre- 
sents a  most  faithful  appearance,  with  its  capsule  half 
torn  off. 

The  rough,  uneven  granular  surface  comes  out  well ; 
while  the  twigs  of  bloodvessels  on  the  thickened  capsule 
are  very  obvious.  Frequently  the  kidney  is  much  less 
in  bulk  than  the  one  here  given  ;  and  especially  when 
greater  length  of  days  is  attained.  The  case  from  which 
the  kidney  was  taken  was  a  middle-aged  woman,  who  was 
cut  off  by  intercurrent  dropsy.* 

Facing  the  title-page  we  see  a  section  of  the  other 
kidney  from  the  same  case  (Stewart).     We  can  see  in  it 

*  Oddly  enough  these  kidneys  were  taken  from  a  case  where  the 
thorax  was  not  opened  ;  but  Dr.  Bright  explains  that  they  closely 
resembled  the  kidneys  of  his  next  case,  where  the  heart  was  found 
enlarged.     The  diminution  in  bulk  goes  hand  in  hand  with  years. 

8—2 


u6  V A  SO-RENAL  CHANGE. 

naked-eye  changes  brought  about  by  the  interstitial  over- 
growth of  connective  tissue,  of  which  we  saw  a  micro- 
scopical section  in  Fig.  14.  The  cortex  is  dragged  down 
to  the  pyramids,  which  are  themselves  invaded.  The 
morbid  change  is  most  pronounced  where  the  two 
atrophied  pyramids  are  drawn  towards  each  other.  The 
plate  gives  one  a  very  vivid  impression  of  the  partial 
and  unequal  invasion  of  the  kidney  structures.  The 
portions  on  each  side  of  the  funnel-shaped  ureter  were 
the  seat  of  recent  inflammation,  or  what  is  known  among 
pathologists  as  '  cloudy  swelling.'  When  pursuing  my 
studies  at  the  Pathological  Institute  of  Vienna,  the 
combination  of  recent  and  old  mischief  in  the  kidneys 
was  seen  recurring  in  a  very  large  proportion  of  cases. 

The  microscopic  appearance  of  the  destroyed  and 
withered  portion  of  those  kidneys  is  represented  in  the 
foregoing  illustrations  (Figs.  13,  14,  15). 

The  destructive  process  is  irregularly  distributed 
throughout  the  kidney;  but  it  may  be  broadly  stated  that 
it  commences  in  the  cortex  and  attacks  the  tubular 
portions  later  on  ;  and  that  at  an  advanced  stage  the 
cortex  is  the  seat  of  more  pronounced  change  than  the 
central  portions. 

Tube-casts. — It  is  this  combination  of  disease  in  various 
stages  in  one  kidney  which,  as  Sir  William  Roberts  points 
out,  gives  the  varying  casts  found  in  the  same  case. 
'  The  diversity  in  the  character  of  the  casts  arises  from 
the  different  condition  of  the  several  parts  of  the  glands. 
In  some  portions  the  tubuli  may  be  denuded  of  their 
epithelium,  and  the  exudation  thrown  into  them  is  dis- 
charged in  the  form  of  large  hyaline  casts  ;  if  the  denuded 
portions    have    undergone    subsequent    contraction,    the 


MIDDLE  STAGE.  117 

casts  will  be  small  and  hyaline.  Other  tubes,  clothed  or 
partially  clothed  with  epithelium,  shed  some  of  their 
cells  with  the  contained  exudation,  and  cause  the  appear- 
ance in  the  urine  of  casts  more  or  less  studded  with 
epithelial  remains.  The  longer  the  exudation  is  retained 
within  the  tubuli,  the  darker  and  more  granular  will  it 
appear  when  discharged  as  casts;  and  vice  versa,  casts 
speedily  discharged  are  commonly  hyaline.  Sometimes 
casts  are  darkened  by  the  colouring  matter  of  the  blood  ; 
and  the  opaque  granular  ones  are  (sometimes  at  least) 
composed  of  crushed  epithelial  debris  moulded  into  the 
form  of  the  tubule.' 

The  existence  of  such  tube-casts  in  the  urine  tells 
unquestionably  that  interstitial  nephritis  is  on  foot ;  but 
they  speak  in  broken  accents  only  as  to  the  extent  of 
kidney  destruction.  Like  every  other  semeion,  they 
must  be  calculated  along  with  the  other  phenomena  of 
each  case.  When  albumen  is  present  in  the  urine,  no 
one  is  justified  in  pronouncing  the  case  to  be  one  of 
'  Bright's  Disease '  until  such  tube-casts  are  detected ; 
and  if  this  were  imperatively  insisted  upon  by  clinical 
teachers,  much  misery  to  patients  and  their  families 
would  be  avoided;  and  also  many  a  rent  and  tear  in  pro- 
fessional reputations.  Still,  even  when  unquestionable 
tube-casts  are  found,  they  only  establish  the  fact  that 
chronic  renal  disease  is  on  foot ;  they  cannot  tell  the 
extent  of  the  disease,  or  give  the  measure  of  the  destruc- 
tion wrought. 

Of  course  where  some  tubular  nephritis  co-exists  with 
vaso-renal  change,  these  tube-casts  are  more  numerous 
than  where  uncomplicated  renal  cirrhosis  alone  is  pre- 
sent.    In  the  last  the  tube-casts  are  scanty,  '  and  it  is  not 


nS  VA SO-RENAL  CHANGE. 

uncommon  for  them  to  be  altogether  absent  for  limited 
periods.'  When  carefully  observed  they  furnish  a  clue 
to  the  nature  of  the  morbid  process  going  on  in  the 
kidneys.  Granular  casts  tell  of  cirrhosis  ;  while  casts 
specked  with  fat  reveal  a  fatty  kidney.  Hyaline  casts, 
large  or  small,  tell  of  chronic  interstitial  nephritis. 

The  accompanying  engraving  shows  the  hyaline  and 
granular  casts  which  are  common  in  the  vaso-renal 
changes.       But    even   tube- casts    have    but    a    restricted 


z'"±. 


Fig.  16. — Tube-casts. — <?,  hyaline  ;  b,  epithelial  :  c,  granular  fatty. 
Magnification,  300  diameters. 


diagnostic  value ;  though  their  presence  along  with 
albuminuria  certainly  decides  the  question  of  kidney 
injury  being  present,  either  as  cause  or  as  coincidence. 
(In  a  case  of  intercurrent  jaundice,  the  hyaline  tube-casts 
were  stained  a  deep  yellow  colour.) 

The  Urine. — That  considerable  modifications  are  under 
these  circumstances  produced  upon  the  renal  secretion, 
is  only  what  could  reasonably  be  expected.  In  the  gouty 
type,  or  Norse  victim  of  vaso-renal  change,  the  bulk  of 
urine  is  copious,  and  its  reaction  is  acid.  Usually, 
especially  in  the  Norse  type,  it  is  clear.  In  the  neurotic 
the  bulk  varies  ;  is  perhaps  less  copious  than  in  the  Norse 


MIDDLE  STAGE.  119 

type,  and  decidedly  more  given  to  throw  down  a  sedi- 
ment ;  while  in  others,  again,  the  bulk  is  not  markedly 
increased,  and  the  specific  gravity  is  from  1020  to  1024 
or  more.  Certainly  variations  in  character  from  the 
copious  pale  urine  of  low  specific  gravity  to  a  concen- 
trated urine  of  high  specific  gravity,  are  more  marked  in 
these  persons  than  in  persons  free  from  this  change.  Of 
course  such  matters  as  pyrexia,  diarrhoea,  diaphoresis, 
affect  the  urine.  A  mitral  lesion  in  the  hypertrophied 
heart  would  profoundly  influence  the  character  of  the 
urine.  Traube's  rule  of  a  copious  urine  going  with  high 
arterial  tension  must  form  the  basis  of  all  calculations  on 
the  subject. 

Dr.  Garrod  examined  carefully  the  urine  of  a  number 
of  persons  suffering  from  chronic  gout;  'the  majority  at 
the  time  the  examinations  were  made  having  no  very 
urgent  symptoms,  but  suffering  from  the  sequelae  of  this 
disease,  as  concretions  of  urate  of  soda  in,  different 
parts  of  the  body,  and  stiffened  and  deformed  joints.' 
(This  evidence  of  the  uric  acid  formation  will  scarcely 
be  challenged  by  anyone,  however  sceptical.)  His  con- 
clusions are  as  follows  : 

■  It  is  rather  paler  than  healthy  urine  of  lower  density, 
and  increased  in  quantity. 

•  The  amount  of  urea,  except  in  extreme  cases,  remains 
much  as  in  health  ;  the  character  of  the  diet  being  taken 
into  consideration. 

'The  uric  acid  is  very  much.diminished,  and  liable  to 
be  excreted  in  an  intermittent  manner.  A  small  amount 
of  albumen  is  very  frequently  present. 

'  The  occurrence  of  deposits  in  the  urine  is  not 
common  ;  they  occasionally  occur  during  the  cooling  of 


120  VA SO-RENAL  CHANGE. 

the  fluid,  either  in  the  form  of  urate  of  soda,  or  as  rhombs 
of  uric  acid,  more  or  less  coloured.' 

Such  is  the  urine  of  persons  of  the  uric  acid  formation 
of  the  Norse  type  in  my  own  experience. 

During  attacks  of  acute  gout  —  'the  thunder-storms 
which  clear  the  air ' — he  found  the  output  of  uric  acid  to 
be  increased  ;  but  again  falling  as  the  attack  passed  off. 

As  to  the  urine  passed  in  acute  gout,  Sir  Charles  Scuda- 
more  wrote  :  '  A  deposition  of  pink  or  brickdust  sediment 
on  cooling  of  the  urine  is  of  such  ordinary  occurrence 
when  any  active  symptoms  of  gout  are  present,  that  its 
connection  becomes  forcibly  impressed  on  the  mind  of 
the  patient,  and  he  gives  it  the  name  of  "  gouty  urine." 

The  sediments  found  with  the  uric  acid  formation  are 
rhombs  of  uric  acid,  looking  like  cayenne  grains,  which 
form  after  the  urine  has  stood  some  hours  ;  and  red, 
pink,  brickdust,  or  fawn  lithates,  the  urates  of  soda  and 
ammonia.  The  first  is  found  with  the  Norse  type,  as  a 
broad  rule ;  the  latter  with  the  neurotic  type.  Oxalates 
are  present  at  times,  and  often  cause  considerable  irrita- 
tion in  the  urinary  passages. 

Sometimes  the  output  of  urates  is  so  copious,  and  the 
urine  so  laden  with  them,  that  the  term  'a  fit  of  the 
gravel'  is  applied  thereto.  They  may  be  formations  of 
various  sizes,  from  what  looks  amorphous  to  the  eye,  up 
to  'sand,'  visible  particles;  or  'calculi'  as  large  as  peas. 
Calculi  form  in  the  tubuli  uriniferi;  and  kidneys  sometimes 
show  a  large  quantity  of  small  uric  acid  concretions.  One 
or  more  of  these  may  fall  into  the  pelvis  of  the  kidney, 
lodge  there,  and  wax  larger.  It  may  stay  there  as  a  renal 
calculus,  producing  its  own  phenomena;  or  it  may  become 
dislodged  and  pass  into  the  ureter,  causing  more  or  less 


MIDDLE  STAGE.  121 

'  renal  colic;'  and  then  find  its  way  into  the  bladder  and 
be  voided ;  or  it  may  lodge  in  the  bladder,  and  reside 
there  as  stone  in  the  bladder, — requiring  an  operation  for 
its  destruction,  or  removal. 

One  of  the  curious  matters  of  which  the  variations  in 
the  vaso-renal  change  furnish  us  with  so  many,  is  the 
localities  haunted  by  stone  in  the  bladder.  It  is  notori- 
ously present  in  the  Eastern  counties  of  Norfolk  and 
Suffolk,  and  again  in  Aberdeenshire.  While  over  other 
large  areas  vesical  calculus  is  an  unknown  disease. 

Uric  acid  has  its  companion  oxalic  acid  ;  and  calculi 
mainly  composed  of  uric  acid,  or  urates  often  exhibit 
layers  of  oxalates.  Oxalates  are  common  in  the  urine  of 
gouty  subjects.  They  are  credited  with  possessing  very 
irritant  properties ;  whether  as  regards  the  brain  and 
irritability  of  temper,  or  as  regards  the  discomfort  they 
produce  in  the  urethra.  The  irritant  urine  of  the  uric 
acid  formation  may  indeed  set  up  cystitis  or  urethritis. 
The  latter  certainly  is  not  uncommon. 

When  an  advanced  condition  of  renal  cirrhosis  is 
reached  the  urine  is  apt  to  be  deficient  in  urea,  to  be  pale 
and  of  low  specific  gravity,  being  1010,  or  as  low  as  1005, 
Such  cases,  or  rather  such  a  condition,  is  of  very  unhopeful 
omen  in  my  personal  experience. 

On  the  other  hand,  where  there  is  a  fairly  normal  urine, 
and  times  of  increased  output  of  urine-solids,  'the  specific 
gravity  may  rise  to  1030,  or  even  1040  '  (Roberts). 

The  bulk  of  the  urine  is  a  matter  too  little  considered 
in  connection  with  the  progress  of  the  vaso-renal  change. 
While  the  blood-pressure  within  the  arteries  is  well 
maintained,  the  bulk  of  urine  keeps  high.  When  the 
heart  begins  to  fail  the  blood-pressure  falls,  and  with  it  the 


122  V A  SO-RENAL  CHANGE. 

bulk  of  urine.  Sir  Wm.  Jenner  has  pointed  out  the 
grave  significance  of  a  fall  in  the  bulk  of  urine.  When  in 
answer  to  the  question,  '  Do  you  pass  as  much  water  as 
you  ever  did  ?'  the  patient's  reply  is,  '  No,  I  do  not 
make  as  much  water  as  I  once  did,'  the  answer  tells  that 
the  patient  has  passed  '  the  turn  of  the  hill,'  and  begun 
the  descent.  Of  scarcely  less  sinister  omen  is  the  change 
betwixt  almost  always  feeling  too  warm,  and  beginning  to 
feel  the  cold.  When  the  individual  who  is  the  victim  of 
the  uric  acid  formation  complains  of  the  cold,  and  con- 
trasts this  state  with  his  previous  indifference  to  cold,  or 
rather  even  enjoyment  of  it,  he  tells  of  having  passed 
'  the  turn  of  the  hill.'  If  the  sensitiveness  to  cold 
co-exists  with  a  gradual  fall  in  the  bulk  of  urine,  then 
it  becomes  possible  to  forecast  the  future,  and  measure 
the  span  of  life  remaining ;  indeed,  to  realize  that  '  the 
spring  is  running  down '  fast. 

Albuminuria. — When  Dr.  Bright  made  the  observation 
that  when  along  with  anasarca  the  urine  was  albuminous, 
there  was  present  disease  in  the  kidneys — a  perfectly  correct 
conclusion — he  probably  little  thought  that  half  a  century 
later  the  anasarca  would  drop  out  of  sight  in  making 
a  diagnosis.  The  detection  of  albuminous  urine  dates 
further  back  than  the  day  of  Dr.  Bright ;  to  whom,  how- 
ever, is  due  the  credit  of  discovering  the  diagnostic  value 
of  the  phenomenon.  As  to  the  precise  import  of  albumen 
in  the  urine  the  greatest  variations  of  opinion  exist.  It 
may  truthfully  be  said  that  its  significance  became  so 
grossly  exaggerated,  that  a  natural  reaction  set  in. 
Medical  practitioners  have  told  me  how  strong  was  the 
hold  of  albuminuria  on  the  medical  mind  some  time  ago, 
that  when  it  was   discovered,  the   patient   was   doomed 


MIDDLE  STAGE.  123 

straight  off ;  and  if  medical  men  found  it  in  their  own 
cases,  they  took  to  their  beds,  and  waited  for  the  advent 
of  the  King  of  Terrors.  But  as  the  latter  failed  to  call, 
after  treading  '  the  valley  of  the  shadow  of  death,'  in 
time  they  took  heart,  left  their  beds  and  went  back  to 
their  work.  A  few  years  later  they  grew  to  laugh  at  the 
bad  scare  they  experienced.  The  fatal  facility  of  the  test- 
tube  and  its  ready  revelations  have  proved  a  temptation 
which  many  could  not  resist.  The  stress  laid  upon  the 
reaction  of  the  urine,  the  ominous  significance  of  albumin- 
uria at  the  examination  table,  have  misled  the  profession 
and  upset  the  mind  of  the  public.  An  indiscreet  medical 
man  finds  albumen  in  a  patient's  urine,  and  tells  him  he 
has  got  '  Bright's  Disease.'  The  patient  has  an  idea  that 
■  Bright's  Disease  is  incurable,'  and  that  he  is  a  doomed 
man.  (Perhaps  he  may  be ;  and  Bright's  Disease  is 
incurable  :  and  we  must  all  die  some  day ;  and  a  goodly 
proportion  of  us  will  perish  by  some  outcomes  of  vaso- 
renal change  sure  enough ;  but  he  need  not  be  in  such 
hurry  about  it  !)  The  utmost  alarm  is  excited,  and  a  very 
distinct  addition  made  to  the  sum-total  of  human  misery. 
When  the  patient  sees  some  other  medical  man  who 
places  the  matter  before  him  with  greater  regard  to  the 
clinical  facts,  the  patient's  mind  is  greatly  relieved  ;  but 
he  feels  very  angry  with  the  medical  opinion  originally 
given  him.  It  is  not  to  decry  examination  of  the  urine 
this  essay  is  written  ;  but  one  distinct  factor  in  the  group 
of  motives  for  writing  it  is  to  enter  a  solemn  and  vigorous 
protest  against  the  too  prevalent  practice  of  diagnosing 
'  Bright's  Disease'  merely  because  the  urine  is  albuminous; 
without  searching  for  other  evidence  of  vaso-renal  change. 
By  presenting  a  fairly  wide  and  comprehensive  view  of  it, 


124  V A  SO-RENAL  CHANGE. 

the  indications  furnished  from  the  kidney  will  be,  or 
at  least  can  be,  corrected  by  the  other  semeia  of  the 
widespread  change.  That  the  evidence  so  readily:  fur- 
nished by  the  test-tube  may  be  weighed  in  the  balance, 
and  appraised  accordingly.  The  medical  observer  once 
taught  to  see  renal  cirrhosis  as  but  a  fragment  of  a  wide- 
spread change,  will  avoid  rash  conclusions  and  erroneous 
inferences  based  on  an  imperfect,  and  too  often  slovenly 
examination  of  the  patient.  This  is  rather  strong  language 
to  employ;  but  its  vigour  falls  short  of  the  crying  necessity 
for  such  outspokenness.  It  is  not  the  knowledge  of 
book-writers  which  is  at  fault — they  enter  their  protests 
honestly  enough  ;  but  the  bent  of  the  rank  and  file 
of  medicine  which  calls  forth  these  comments.  It  is 
enough  to  make  one  despair  of  the  reasoning  powers 
of  one's  species  to  contemplate  an  age  which  refuses  to 
discriminate  betwixt  albuminuria  and  Bright's  Disease  ; 
betwixt  glycosuria  and  diabetes ;  and  which  persists  in 
regarding  beef-tea  as  a  sustaining  food  ! 

Sir  Thomas  Watson  faced  the  issue  boldly,  and  with 
his  wonted  clear-sightedness.  In  discussing  the  subject 
of  Bright's  Disease,  he  wrote :  '  Two  questions  of  great 
interest  at  once  present  themselves  : 

'  i.  Does  albuminous  urine  always  imply  the  presence  of 
Bright's  Disease  ? 

'  2.  Is  Bright's  Disease,  when  present,  always  accom- 
panied by  albuminous  urine  ? 

'  To  both  these  questions  the  answer  is — No.' 

Nothing  could  be  fairer  than  this  position.  It  is  one 
simply  unassailable.  As  to  what  extent  albuminuria  is 
found  with  the  vaso-renal  change,  no  one  observer  is  in  a 
position  to  say.     Experiences  vary.     One   man's  experi- 


MIDDLE  STAGE.  125 

ence  does  not  tally  exactly  with  another  man's.  One 
medical  man  will  recount  the  cases  where  he  formed  a 
grave  prognosis  from  the  presence  of  albumen  in  the 
urine.  Another  will  tell  of  the  number  of  times  he  has 
seen  albuminuria  not  followed  by  anything  sinister.  Sir 
Joseph  Fayrer,  a  little  time  ago  told  me  of  a  case  where 
the  patient's  urine  had  contained  notable  quantities  of 
albumen  persistingly  for  twelve  years.  Yet  the  man  was 
in  good  health. 

We  all  recognise  the  fact  that  when  a  gouty  man  ad- 
vancing in  years  passes  a  small  quantity  of  albumen 
pretty  steadily,  we  do  not  like  the  prospect.  When  the 
heart  is  failing  and  albumen  begins  to  show  itself  in  the 
urine  we  recognise  it  as  the  herald  of  disaster.  But  there 
are  many  circumstances  where  albumen  is  present  in  the 
urine  which  cause  it  to  be  a  riddle  not  easy  to  read  ;  and 
too  often  a  puzzle  of  Sphinx-like  character.  As  regards 
my  own  personal  position  in  the  matter,  it  is — that  one 
casual  examination  of  the  urine  may  give  its  general  cha- 
racteristics, but  cannot  entitle  it  to  be  taken  as  a  guide  ; 
and  that  repeated  examinations  extending  over  some  time 
are  requisite  to  careful  diagnosis.  As  in  a  great  many 
instances  the  patient  can  only  give  one,  or  at  most  two, 
opportunities  for  such  observation,  and  as  the  urine  varies 
more  from  day  to  day  in  persons  undergoing  the  vaso- 
renal change  than  in  perfectly  healthy  person,  I  have  cast 
about  for  other  semeia  permanently  present  ;  and  trust 
more  to  the  grouping  of  symptoms,  the  tout  ensemble  of  the 
case — not  forgetting  the  urine — than  to  the  examination  of 
the  urine,  as  the  only  safe  infallible  guide.  My  position  is 
the  outcome  of  my  own  personal  experience ;  which  must 
just  be  taken  for  what  it  is  worth.     One  further  word  on 


126  VASO-RENAL  CHANGE. 

this  subject.  It  is  much  easier  to  detect  albumen  in  the 
urine  than  to  appraise  its  significance  when  found  !  There 
are  circumstances  where  its  presence  excites  no  anxiety  ; 
there  are  conditions  where  its  absence  conveys  no  com- 
fort. Frequently  the  evidence  of  vaso-renal  change  is  so 
complete  that  it  is  a  matter  of  comparative  indifference 
what  the  reaction  of  the  urine  may  be  ;  if  free  from  albu- 
men it  does  not  disqualify  the  other  evidence  ;  if  albumen 
be  present,  that  fact  cannot  add  to  the  gravity  of  the  case. 

Certainly,  when  the  urine  is  found  to  be  albuminous  no 
sensible  or  prudent  man  would  dismiss  the  matter  as 
trivial,  or  unimportant. 

The  necessity  for  repeated  examinations  extending  over 
some  considerable  time  is  furnished  by  the  fact  that  a 
New  York  Insurance  Company  has  found  the  urine  to 
present  evidence  of  the  presence  of  albumen  in  one  in 
every  eleven  cases  ;  while  Leube  found  the  urine  of  four 
out  of  iig  soldiers  to  present  evidence  of  albumen  in  the 
morning,  and  no  less  than  sixteen  to  do  the  same  after 
a  march.  A  solitary  examination  of  the  urine  is  a  sorry 
guide  to  rely  upon.  And  as  two  consultations  are  about 
the  average  of  patients'  visits  to  a  London  consultant ; 
unless  the  said  consultant  has  got  some  other  evidence  to 
guide  him,  and  on  which  he  can  rely  in  forming  his 
opinion,  other  than  that  furnished  by  the  urine,  it  seems 
to  me  that  the  opinion  would  be  of  very  little  value  to  the 
patient. 

The  circumstances  under  which  peptones  find  their  way 
into  the  urine  are  scarcely  yet  quite  clear  to  us  ;  but  we 
know  they  are  apt  to  appear  when  the  liver  is  out  of 
order — and  that  is  a  common  accident  with  persons  under- 
going the  vaso-renal  change. 


MIDDLE  STAGE.  127 

Again,  a  dietary  '  rich  in  albuminoids  '  is  apt  to  cause 
albumen  to  be  present  in  the  urine  ;  but  '  rich  '  is  a  com- 
parative term.  What  may  be  quite  a  normal  amount  of 
albuminoids  for  persons  of  the  Norse  variety  may  readily 
enough  be  '  rich  '  to  another  of  the  Neurotic  type — '  rich  ' 
enough  to  cause  the  urine  to  be  albuminous  ! 

The  subject  of  albuminuria  and  the  significance  of 
albumen  in  the  urine  is  not  a  matter  to  be  dismissed 
summarily.  And  the  writer  trusts  that  what  has  been 
written  here  pro  and  con.,  will  be  'read,  marked,  learned 
and  inwardly  digested '  by  the  reader  as  worthy  of 
consideration ;  and  having  a  direct  bearing  on  practice. 
And  let  him  not  forget  that  in  Quain's  '  Dictionary  of 
Medicine,'  Dr.  Lauder  Brunton,  F.R.S.,  draws  the 
distinction  betwixt  '  true  '  and  '  false  '  albuminuria. 

Glycosuria. — It  is  now  a  well-recognised  clinical  fact 
that  persons  of  the  uric  acid  formation  are  liable  to  pass 
quantities  of  sugar  in  their  urine.  That  the  liver  which 
reveals  its  incompetence  by  reversion  to  the  formation  of 
primitive  urine-stuff,  should  manifest  derangements  as  to 
its  glycogenic  arrangements,  need  occasion  no  surprise  to 
anyone,  to  my  way  of  thinking.  Garrod  has  observed 
that  gouty  persons  are  liable  to  pass  saccharine  urine ; 
and  the  same  observation  has  been  made  by  others.  It 
certainly  falls  in  with  my  own  experience.  A  considerable 
number  of  gouty  persons  pass  sugar,  to  my  personal 
knowledge.  Just  as  emotion  affects  the  lachrymal  glands, 
arousing  their  activity,  and  the  salivary  glands  by  arrest- 
ing their  action,  so  does  it  affect  the  liver  ;  as  seen  in 
the  production  of  jaundice  by  mental  shock,  or  surprise, 
and  in  acute  diabetes  from  like  causes.  The  production 
of  glycosuria,   often   deepening  into  diabetes  by  carking 


128  VASO-RENAL  CHANGE. 

care,  or  prolonged  anxiety,  from  business  or  other  cause, 
is  now  widely  recognised.  C.  Creighton  holds  that  persons 
who  do  not  betray  emotion  readily,  and  who  carry  them- 
selves stoically  under  trials,  are  especially  liable  to  have 
their  livers  deranged ;  and  some  other  trustworthy 
observers  hold  the  same  view.  True  diabetes  seems  to 
me  to  have  a  special  affinity  for  persons  of  the  neurotic 
type,  while  glycosuria  is  common  with  persons  of  the  Norse 
type.  When  the  general  nutrition  does  not  suffer,  the  case 
may  be  classed  fairly  enough  as  '  glycosuria ;'  where  the 
general  nutrition  suffers,  then  the  term  '  diabetes '  is 
correct.  A  glycosuric  person  may  be  liable  to  acute 
'  diabetic  storms '  from  time  to  time ;  as  is  not  unfrequently 
the  case. 

Glycosuria  is  linked  with  the  uric  acid  formation  by 
other  ties  than  the  fact  that  persons  of  this  formation  are 
liable  to  glycosuria.  There  is  another  matter  to  be 
considered.  The  person  with  glycosuria  is  often  put 
upon  a  dietary  rich  in  albuminoids  ;  this  was  a  practice 
of  the  French  school  a  generation  ago,  and  still  too 
commonly  prevalent.  In  keeping  the  vision  directed  to 
the  prevention  of  sugar-formation  too  exclusively,  the 
fact  of  the  excess  of  albuminoids,  and  the  consequences 
thereof,  is  apt  to  be  lost  sight  of.  Yet  this  is  not  une 
quantite  negligeable  by  any  means. 

While  it  is  perfectly  true  that  many  robust  gouty 
persons  pass  quantities  of  sugar;  and  that,  too,  not  always 
as  a  transient  affair,  but  persistently  for  long  periods 
without  any  ill  effects  resulting  therefrom  :  it  is  equally  a 
clinical  fact  that  old  subjects  of  the  vaso-renal  change 
often  burn  out  at  last  with  saccharine  urine.  They  have 
worn  well  and  are  well  stricken  in  years,  when  they  begin 


MIDDLE  STAGE.  129 

to  lose  flesh,  and  sugar  is  found  in  the   urine  ;  and  in 
a  little  time  it  is  all  over  with  them. 

In  glycosuria,  as  in  albuminuria,  rash  conclusions  are 
to  be  deprecated  as  apt  to  be  misleading.  Either  condi- 
tion ought  to  evoke  careful,  thoughtful  consideration.  In 
the  matter  of  glycosuria,  its  mode  of  origin,  its  march,  and 
the  circumstances  of  the  individual  should  all  be  rigorously 
investigated  ;  and  the  information  elicited  be  made  the 
subject  of  thoughtful  ratiocination.  If  the  patient  be 
a  neurotic  individual,  giving  evidence  of  the  vaso-renal 
change,  and  looking  older  than  his  years,  in  my  opinion, 
the  matter  of  his  burden  of  care  or  worry — how  far 
he  can  escape  from  it ;  how  far  it  is  fastened  upon  him 
inextricably — is  not  a  factor  to  be  lost  sight  of,  or  left  out 
of  the  calculation  as  to  the  prognosis  of  the  case. 

In  fact  it  is  often  possible  for  the  reflecting  physician 
to  be  of  much  practical  service  to  his  patients,  beyond 
merely  treating  their  passing  maladies.  If  he  possess  a 
competent  acquaintance  with  the  long  chronic  morbid 
process  (some  account  of  which  has  been  given  in  these 
pages),  he  will  often  be  able  to  detect  the  oncoming 
of  disease — long  before  its  progress  is  obvious  to  the 
untrained  eye.  An  active  business  man  comes  to  him 
complaining  of  '  not  being  up  to  the  mark  ;'  being  listless 
in  mind  and  body,  and  losing  flesh.  An  examination  of  the 
urine  reveals  the  presence  of  sugar.  The  note  of  alarm 
is  at  once  sounded.  Not,  as  in  a  case  reported  to  me 
some  time  ago,  where  on  such  discovery  the  medical  man 
hastened  to  the  patient's  wife,  and  abruptly  told  her  that 
her  husband  had  got '  Diabetes.'  With  as  little  considera- 
tion, in  turn,  she  told  her  husband  what  the  doctor  had 
said  ;  upon  which  the  poor  man  exclaimed  :  '  Then  I  am 

9 


13©  VA SO-RENAL  CHANGE. 

a  dead  man!'  and  in  less  than  a  week  he  drew  his  last 
breath.  Instead  of  such  brutal  thoughtless  behaviour  the 
reader  of  this  essay  will,  it  is  my  earnest  hope,  break  the 
matter  gently  to  the  patient — as  is  his  duty  as  a  neighbour 
and  a  man ;  explain  to  him  the  facts  of  the  case,  and  the 
necessity  for  some  rest  for  cure  ;  and  some  lightening  of 
the  load  he  carries  for  the  future.  To  make  him  under- 
stand that  it  is  no  more  inevitable  that  a  case  of  glyco- 
suria will  march  steadily  on  to  the  grave,  by  the  route  of 
confirmed  diabetes,  than  that  a  person  with  incipient 
phthisis  shall  succumb  to  consumption ;  or  a  man  in 
temporary  financial  embarrassment  will  of  necessity 
become  a  bankrupt.  Nor  when  a  neurotic  is  complaining 
of  indigestion,  acidity  and  flatulence,  losing  flesh,  passing 
lithates,  and  subject  to  sharp  neuralgic-colicky  pains  across 
the  transverse  colon,  to  diagnose  inflammation,  and  inject 
morphia;  by  which  the  incapable  liver  is  further  depressed; 
and  then  try  to  feed  up  the  sufferer  by  plenty  of  animal 
food  which  is  just  so  much  poison  to  him — as  happened 
to  a  New  England  patient  of  mine  lately.  When  he  finds 
such  a  person  becoming  sleepless  he  can  warn  him  of  the 
coming  trouble  ahead  of  him — if  he  does  not  slacken  the 
pace  at  which  he  is  going. 

We  are  beginning  to  realize  what  the  old  physicians 
call  the  pathemata  mentis,  the  effect  of  mental  conditions 
upon  visceral  conditions ;  of  the  reaction  of  the  tissues  of 
the  epiblast  upon  those  of  the  hypoblast ;  and  vice  versa. 
Not  only  does  the  overworked  man  injure  his  own 
assimilative  processes,  but  he  impairs  those  of  his 
children.  '  What  is  acquired  by  the  father  is  inherited 
by  the  child  ;'  and  this  does  not  apply  solely  and  merely 
to   worldly   goods.      Again    it    is    a   case    of  the    fathers 


MIDDLE  STAGE.  131 

having  eaten  sour  grapes  and  the  children's  teeth  being  set 
on  edge.     One  American  lady  after  another,  complaining 
of   digestive    troubles,   and    exhibiting    evidences    of  the 
neurotic  aspect  of  the  vaso-renal  change,  has  told  me  of 
the  energy  displayed  by  her  father,  for  a  long  period  of 
years ;  until  the  impression  has  been  forced  upon  me  that 
the  two  have  something  more  than  an  accidental  associa- 
tion.    And  this  small  fact  stands  in  a  certain  suggestive 
relation   to  the   great   fact  that   the    inhabitants    of  the 
United    States    of  America   are    at    once  active-minded, 
industrious,  and  dyspeptic.     It  is  not  merely  their- dietetic 
outrages  as  to  choice  of  food,  and  the  little  consideration 
they  give  the   stomach  by  taking  their  meals   in    haste, 
instead  of  in    a   leisurely  rational    manner;    which   give 
primary  gastric  derangement.     And  the  person  reaps   as 
he    sows !     The   long   mental    strain    is    not  borne    with 
impunity.     Nature  takes  her  revenge  upon  the  liver.     The 
hard-working  man  not  only  impairs  the  efficiency  of  his 
own  liver;    but   his   children   come   into   the    world   with 
insufficient,  or   incapable  livers.     The  liver   governs   the 
appetite    for    food ;    and    consequently   such    beings    are 
naturally  and  instinctively  small  eaters.     But  mankind  is 
impressed  with  the  idea  that   every  day  so  much    food 
ought  to  be  taken — as  one  of  the  fundamental  laws  of  the 
universe — and  that  if  a  child  be  delicate  it  ought  to  be 
'  fed  up.' 

Old  Dame  Nature,  in  her  kindly  thoughtful  way,  has 
made  the  child  a  dainty  fastidious  eater,  with  a  small 
appetite — as  a  protection  for  the  feeble  liver ;  but  in 
vain  !  Her  purpose  is  ruthlessly  thwarted  ;  with  the  best 
intentions,  doubtless  !  By  precept  the  child  is  en- 
couraged to  eat  more  than  it  wants ;  while  it  is  tempted 

9—2 


U2  V A  SO-RENAL  CHANGE. 

by  delicacies  of  all  kinds.  Nature  is  trying  to  level 
down  the  physique  to  the  liver ;  and  when  her  plans  are 
rudely  traversed,  she  resents  the  outrage  ;  and  pays  it  out 
by  liver-reversion,  and  the  formation  of  uric  acid.  Now 
the  intelligent  physician,  perceiving  the  real  facts  of  the 
case,  will  be  able  to  interpose  on  the  poor  child's  behalf; 
just  as  a  man  would  in  any  other  relation  in  life  when  a 
child  is  being  oppressed — and  stay  their  tyrannical 
efforts.  Of  course  this  will  be  more  difficult  at  first  than 
when  the  lay  world  has  become  familiar  with  this 
matter ;  and  the  fact  that  vaso-renal  change  is  to  a 
great  extent  an  outcome  of  modern  life,  is  generally 
realized. 

It  is  needless  to  multiply  examples  of  how  the  phy- 
sician may  be  able  to  help  his  fellow-creatures  by  certain 
knowledge  ;  and  feel  his  hands  strengthened,  not  only  to 
cure  but  to  save  and  prevent,  by  familiarity  with  morbid 
processes  extending  over  long  years.  Even  something 
more  is  possible ;  he  may  be  able  to  correctly  estimate  a 
child's  inherited  physique,  and  so  wisely  guide  its  up- 
bringing, and  control  its  rearing,  as  to  enable  it  to  grow 
in  a  favourable  manner ;  and  so  to  lessen,  and  not  intensify 
its  inherited  proclivities. 

Indeed,  he  may  so  digest  and  arrange  his  knowledge  as 
to  make  it  available  in  the  way  of  guiding  men  and 
women,  as  to  their  own  ways  and  modes  of  living  ;  and, 
more  than  that,  of  correcting  the  inherited  tendencies  of 
their  offspring.  And  this  is  only  the  more  necessary  as 
the  tendency  to  move  in  the  direction  of  the  neurotic 
is  waxing  stronger  day  by  day  ;  especially  amongst  urban 
populations.  As  to  the  subject  last  discussed,  viz., 
glycosuria,    our    acquaintance  with    the    malady   is    now 


MIDDLE  STAGE.  133 

such  that  infinitely  more  valuable  advice  and  suggestions 
can  now  be  given  to  a  patient,  than  was  humanly  possible 
twenty  years  ago  ;  and  this  chiefly  by  recognition  of  the 
reaction  between  epiblast  and  hypoblast — between  the 
brain,  as  the  organ  of  mind,  and  the  glandular  apparatus 
of  the  assimilative  organs. 

Results  of  Toxic  Blood. — There  are  a  series  of  morbid 
manifestations  in  persons  who  are  the  subject  of  vaso- 
renal change,  which  take  their  origin  in  waste-laden,  or 
imperfectly  depurated  blood.  Whether  this  last  is  due  to 
excessive  formation  of  abnormal  rather  than  normal 
products  by  the  liver  to  some  extent,  with  imperfect 
excretory  action  in  the  kidney ;  or  the  latter  alone  exists, 
is  a  matter  of  secondary  moment.  The  blood  is  laden 
with  products  of  albumen-metamorphosis — that  is  the 
cardinal  fact.  It  is  when  the  kidneys  become  distinctly 
inadequate,  and  waste  matters  accumulate  in  the  blood, 
that  we  see  the  most  pronounced  evidence  of  vaso-renal 
change  being  a  long,  persistent,  sustained,  and  often 
desperate  attempt  of  the  system  to  depurate  the  blood. 
These  morbid  manifestations  affect  the  brain,  the  serous 
membranes,  the  mucous  membranes,  the  lungs  and  the 
skin. 

Urcemia. — This  is  the  term  applied  to  the  condition 
when  the  sensorium  is  affected.  Headache  is  common — 
sometimes  it  is  hemicrania ;  or  in  another  individual  the 
pain  is  felt  across  the  forehead,  and  at  times  at  the 
occiput  or  nape  of  the  neck.  Very  frequently  the  pain  is 
vertical.  The  vision  is  influenced;  being  more  or  less 
completely  lost  at  times.  The  hearing  is  less  commonly 
affected.  Drowsiness  is  often  present.  There  are  twitch- 
ings    of  the  voluntary  muscles.     When   a  more  intense 


134  V A  SO-RENAL  CHANGE. 

condition  is  present,  there  are  convulsions  of  the  epileptic 
type  with  coma.  Very  often  such  a  condition  is  accom- 
panied by  vomiting  ;  the  vomited  matter  either  being 
ammoniacal,  or  of  a  urinous  odour  ;  and  soon  undergoing 
ammoniacal  decomposition.  If  a  microscopic  slide  be 
moistened  with  hydrochloric  acid  and  held  under  the 
nose,  crystals  of  hydrochlorate  of  ammonia  are  quickly 
formed.  The  condition  of  uraemia  is  a  very  serious  one, 
fraught  with  great  danger  to  life  when  convulsions  and 
coma  appear  ;  while  death  from  effusion  into  the  brain  is 
a  common  termination.  At  other  times  the  paroxysm  is 
survived.  The  condition  varies  ;  sometimes  the  insensi- 
bility betwixt  the  convulsions  is  complete  ;  while  in  other 
cases  the  drowsy  sufferer  can  be  roused.  In  a  case  seen 
in  the  Hospital  of  Vienna,  the  unconsciousness  deepened, 
and  then  lifted  at  short  intervals ;  so  as  to  remind  one 
of  a  mist  rising,  and  settling  again.  The  condition  of 
uraemia  may  alternate  with  that  of  some  other  outcome 
of  the  toxic  state  of  the  blood. 

Secondary  Inflammations. — These  may  attack  the  serous 
membranes,  and  frequently  threaten  life  ;  the  pleura,  the 
peritoneum,  the  pericardium,  or  the  meninges  of  the  brain 
being  affected. 

Then  the  mucous  membranes  feel  the  effects  of  the 
waste-laden  blood.  Bronchitis  is  common  ;  the  sputem 
being  distinctly  acid  when  the  affection  is  chronic.  At 
other  times  there  is  muco-enteritis  ;  with  the  discharge  of 
fluid  of  urinous  odour,  and  readily  undergoing  ammo- 
niacal decomposition.  This  diarrhoea  is  of  a  compensa- 
tory character,  and  should  not  rashly  be  interfered -with. 
The  late  Dr.  Carpenter,  in  his  article  on  '  Secretion  '  in 
the  '  Cyclopaedia  of  Anatomy  and  Physiology,'  points  to 


MIDDLE  STAGE.  135 

the  fact  that  each  excretory  organ  is  capable  of  supple- 
menting the  function  of  another  organ,  when  defective  or 
embarrassed  ;  and  eliminating  material  special  to  the 
other  organs  rather  than  itself:  a  property  which  they 
possess  as  mere  modification  of  the  general  excretory 
surface  of  the  lower  forms  of  life.  Thus  the  kidneys 
cast  out  bile  in  jaundice ;  the  bowel  urinary  salts  in 
Bright's  disease.  When  such  diarrhcea  is  present,  it  is 
well  to  bear  the  fact  in  mind  ;  and  not  arrest  the  diarrhoea 
until  the  action  of  the  kidneys  is  established.  By  so 
doing  in  my  early  days  of  general  practice,  an  old  lady, 
the  subject  of  vaso-renal  change,  was  tided  over  an  attack 
of  uraemic  diarrhoea  which  gravely  threatened  life  ;  though 
my  masterly  inactivity  only  procured  me  some  odium — 
my  motives  not  being  comprehended  by  my  critics. 

Inflammation  of  the  lungs  is  certainly  often  secondary,, 
and  due  to  the  toxic  properties  of  the  blood.  In  one 
such  case  seen  in  early  days,  where  the  urine  was  dis- 
tinctly bloody,  the  pneumonia  readily  yielded  to  a  mixture 
of  potash  with  nitric  ether  and  juniper.  Nor  is  such  a 
case  exceptional  by  any  means. 

The  skin  is  liable  to  prurigo  (as  in  jaundice),  to  im- 
petigo, herpes  zoster,  and  eczema.  Erysipelas  is  not 
rare  :  it  may  extend  over  a  lower  extremity,  or  be  con- 
fined to  the  face.  The  skin  becomes  thin — in  some  cases 
almost  like  a  sheet  of  paper,  or  parchment ;  and  this  is 
very  conspicuous  when  distended  by  anasarca.  In  one 
such  case  seen  a  few  years  ago,  after  an  attack  of  lung- 
inflammation  (set  up  by  a  long-continued  fog)  the  legs 
swelled.  The  gentleman,  an  old  victim  to  gout,  was 
severely  tried  by  the  lung-trouble  ;  and  when  an  erysipe- 
latous blush  spread    over  one   leg,   with    one   dark   spot 


136 


VASO-RENAL  CHANGE. 


about  the  size  of  a  florin,  which  seemed  as  if  about  to 
slough  out  ;  Sir  Joseph  Fayrer  and  myself  quite  thought 
the  end  was  at  hand.  But,  despite  the  unfavourable 
circumstances,  the  old  gentleman  rallied  and  recovered. 

The  great  matter  to  remember  in  the  treatment  of 
conditions  secondary  to  vaso-renal  change,  is  the  condi- 
tion of  the  blood  ;  which  is  the  exciting  cause.  Instead  of 
following  the  treatment  appropriate  to  primary  disease  of 
like  character,  the  most  effective  measure  is  to  sweep  the 
waste  matters  out  of  the  blood  as  speedily  as  may  be. 
This  can  be  done  by  alkaline  cathartics  and  diuretics 
pushed  freely ;  while  the  skin  is  thrown  into  action  by 
external  heat  and  moisture.  But  the  practitioner  must 
know  what  he  is  doing  in  order  to  act  aright.  The  great 
necessity  for  comprehending  how  '  secondary '  inflamma- 
tions differ  from  'primary'  inflammation  was  unfortunately 
seen  lately.  A  gouty  gentleman  had  acute  articular  gout, 
which  was  suppressed  ;  with  the  result  of  peritonitis.  The 
metastasis  never  struck  the  medical  man  in  attendance ; 
who  pushed  opium,  with  a  fatal  result. 

As  to  the  complications  found  with  the  vaso-renal  change, 
they  are  well  illustrated  by  the  accompanying  table  of  four 
hundred  cases  collected  by  Sir  William  Roberts,  M.D.  : 


Heart. 

Lungs. 

Pleura. 

Pericardium. 

Peritoneum. 

Peritoni- 
tis, 45 

Hypertro- 
phy, 125 

H.  with  val- 
vular dis- 
ease, 54 

CEdema,  115 
Pneumonia,  52 
Pn.  Apoplexy,  8 
Gangrene,  4 
Tubercle,  37 
Vesicular     Em- 
physema, 33 

Pleurisy,  57 

Pericardi- 
tis, 30 

MIDDLE  STAGE. 


127 


Liver. 

Spleen. 

Stomach  and 
Intestines. 

Brain. 

Cirrhosis,  41 
Fatty  liver,  38 
Nutmeg  liver,  11 
Lardaceous,  3 

Chronic  tumour, 

58 
Acute    splenitis, 

17 
Contracted 
spleen,  9 

Gastric   catarrh, 

Catarrh, with  fol- 
licular ulcera- 
tion of  intes- 
tines, 85 

Tuberculosis  of 
intestines,  13 

Sanguineous 
apoplexy,  14 

Effusion  ot 
serum  under 
arachnoid,  59 

Tumour  cere- 
bri, 11 

Chronic  ar- 
achnitis, 6 

This  gives  at  a  glance  the  morbid  outcomes  of  the  vaso- 
renal change.  It  is  somewhat  remarkable  that  there  is 
no  account  of  aneurysm. 

Gouty  Asthma. — The  effect  of  uric  acid  upon  the  respi- 
ratory centre  is  interesting.  Girls  with  the  uric  acid 
diathesis  are  liable  to  attacks  of  bronchial  spasm  when- 
ever there  is  any  bronchial  irritation  ;  and  such  a  con- 
dition is  common  in  the  first  stage  of  acute  bronchitis. 
At  times  there  is  dyspncea — certainly  not  the  result  of  any 
mischief  in  the  lung,  and  clearly  neurosal.  The  neurotic 
is  liable  to  distinct  attacks  of  asthma.  Then,  of  course, 
the  old  gouty  man  with  chronic  bronchitis  and  emphysema, 
has  times  of  distinct  bronchial  spasm.  (He  has,  however, 
also  acute  attacks  of  difficulty  of  breathing,  from  the 
sudden  evolution  of  gas  in  the  intestines  preventing  the 
descent  of  the  diaphragm.)  Sometimes  there  is  a  distinct 
embarrassment  of  the  breathing,  lasting  for  several  days. 
One  such  experience  befell  myself  two  years  ago.  After 
lasting  two  days,  a  sharp  action  of  the  bowels  occurred 
about  five  o'clock  in  the  morning — the  contents  of  the 
evacuation  being  highly  bilious.  A  sound  sleep  followed  ; 
and,  on  awakening  at  the  usual  hour,  the  embarrassment 


13S  V A  SO-RENAL  CHANGE. 

of  the  breathing  had  so  entirely  disappeared  that  it  was 
difficult  to  realize  that  it  had  been  so  recent. 

Nocturnal  dyspnoea  is  not  uncommon.  It  seems  as  if 
the  respiratory  centre  partially  slept ;  and  an  accumulation 
of  carbonic  acid  in  the  blood  roused  the  centre  to  great 
activity.  After  a  little  energetic  or  hard  breathing,  the 
condition  of  affairs  is  rectified  ;  and  then  sleep  soon 
follows.  This  has  been  noticed  by  Basham,  who  terms 
them  '  inexplicable  fits  of  difficult  breathing.'  They  differ 
from  attacks  of  true  cardiac  dyspnoea  in  being  altogether 
less  severe  and  sooner  over. 

Dupuytreii's  Contraction. — This  is  a  growth  of  connective 
tissue  in  the  palm,  over  a  flexor  tendon — usually  that 
of  the  ring-finger.  It  extends  to  the  sheath  of  the  tendon, 
and  gradually  brings  the  finger  down.  Sir  James  Paget 
has  traced  its  connection  with  gout ;  and  certainly  it  has 
a  high  diagnostic  value  in  times  of  doubt.  It  usually 
occurs  in  the  right  hand  ;  and  is  attributed  to  the  walking- 
stick,  or  umbrella-handle.  Possibly  enough,  these  are  the 
exciting  causes ;  but  there  is  something  else  as  well.  One 
old  gentleman  who  had  it  in  his  left  hand  explained  its 
presence  as  being  due  to  his  geological  specimens ;  which 
rested  on  his  left  palm  while  he  exercised  his  hammer 
upon  them.  That  there  are  exciting  causes  in  action  may 
at  once  be  admitted  :  but  then  there  is  something  lying 
beneath  which  permits  these  causes  to  operate ;  and  that 
evidently  is  the  uric  acid  diathesis.  Outward  applications 
of  iodine  do  no  good  ;  and  operative  proceedings  are  not 
satisfactory,  as  the  results  are  temporary. 

Albuminuric  Retinitis. — Another  curious  local  growth  of 
connective  tissue,  in  the  vaso-renal  change,  takes  place  in 


MIDDLE  STAGE.  139 

the  retina.     R.  Marcus  Gunn  has  provided  me  with  this 
brief  account  of  it : 

'  It  is  most  commonly  associated  with  chronic  renal 
disease  ;  especially  the  contracting  form.  It  has  been 
observed  in  about  thirteen  per  cent,  of  all  cases  of 
albuminuria.  Ophthalmoscopically  we  find  numerous 
soft-edged  patches,  mainly  in  the  neighbourhood  of  the 
optic  disc,  and  behind  the  renal  vessels ;  and  minute 
opaque,  very  white  dots  or  striae  at  the  yellow  spot, 
arranged  in  the  form  of  an  asterisk,  with  its  centre  at  the 
fovea  centralis.  The  large  spots  nearer  the  disc  occur 
earlier  than  the  dotted  arrangement  at  the  maculae. 
Besides  these  more  typical  retinal  changes,  we  may  also 
have  numerous  haemorrhages  in  the  nerve-fibre  layers  ; 
especially  in  cases  where  the  papilla  is  much  swollen. 
Not  infrequently,  too,  the  retinal  arteries  are  unusually 
conspicuous,  from  their  walls  reflecting  more  light  than 
do  those  of  healthy  vessels.  Both  eyes  are  always  prac- 
tically affected. 

'  Pathology. —  (1)  Changes  in  vessels  :  There  is  sclerosis  of 
the  walls  of  the  smaller  arteries.  The  larger  vessels  ex- 
hibit less  sclerosis  ;  but  their  adventitia  is  often  markedly 
hypertrophied.  (2)  Changes  in  the  retina  :  The  large  soft- 
edged  patches  are  principally  due  to  the  deposit  of  cells 
loaded  with  fatty  granules  in  the  middle  layer  of  the 
retina.  The  minute  dots  at  the  maculae  are  caused  by 
fatty  infiltration  of  the  inner  ends  of  the  Miillerian  fibres 
in  this  situation.  Besides  this  fatty  change  in  the  radial 
fibres,  they  are  found  to  be  both  elongated  and  thickened  ; 
and  sometimes  to  have  papillary  outgrowths  of  connective 
tissue  springing  from  them.     Frequently  the  nerve-fibres 


140  V A  SO-RENAL  CHANGE. 

on  the  disc,  and  in  its  immediate  neighbourhood,  undergo 
a  varicose  sclerosing  hypertrophy.' 

We  see,  then,  a  growth  of  connective  tissue,  both  in  the 
retinal  laj'ers  and  the  walls  of  the  small  arteries.  And 
both  here  and  in  Dupuytren's  contraction,  we  see  marked 
illustrations  of  that  growth  of  lowly  connective  tissue  ; 
which  was  laid  down  in  Chapter  II.  as  the  anatomical 
departure  par  excellence  of  the  vaso-renal  change. 

The  middle  stage  extends  over  a  considerable  period  ; 
being  established  in  some  instances  at  about  the  age  of 
forty-five ;  and  passing  into  the  final  stage  shortly  after 
sixty.  In  my  own  experience  this  rapid  career  has  taken 
place  in  licensed  victuallers  mainly.  In  other  cases  the 
middle  stage  is  not  well  established  till  the  age  of  sixty; 
and  the  final  stage  sets  in  about  seventy-five.  But  in 
some  families  the  breakdown  is  later  still ;  and  the  spring 
runs  down  very  slowly. 


CHAPTER  V. 

ADVANCED    STAGE. 

Ceneral  Considerations — Lead — Occlusion  of  the  Coronary  Vessels  with 
Fatty  Degeneration  of  the  Heart— Arcus  Senilis— The  Descent- 
Venous  Fulness  —  Interstitial  Changes  —  Dropsy — Albuminuria — 
Serous  Effusions — Death,  Sudden  or  Slow. 

PROLOGUE. 

At  this  point  some  general  considerations  seem  called  for, 
which  can  now  be  discussed  with  advantage. 

Without  a  certain  familiarity  with  the  widespread 
change  sketched  in  the  preceding  chapters,  it  is  difficult 
for  any  medical  man  to  grasp  the  entirety  of  a  case  ;  when 
some  particular  outcome  of  this  change  is  the  immediate 
cause  why  the  person  of  advanced  years  calls  in  medical 
aid.  It  may  be  an  attack  of  bronchitis,  or  may  be  pleurisy, 
or  diarrhoea,  or  eczema,  or  angina  pectoris,  or  neuralgia, 
or  gout  ;  it  matters  little  what,  it  is  only  the  prominent 
feature  of  the  case — that  portion  of  a  great  widespread 
and  invisible  morbid  change  which  is  visible.  A  great 
many  matters  are  apt  to  remain  shrouded  in  darkness,  if 
the  associations  of  the  particular  malady  are  not  clearly 
recognised.  The  medical  man  is  called  in  to  a  case  of 
apoplexy.  If  he  find  a  large  heart,  and  a  hard  artery; 
and  bear  in  mind  what  Rokitanski  observed  :  he  will  see 


142  \' A  SO-RENAL  CHANGE. 

that  unless  he  can  promptly  lower  the  blood-pressure 
in  the  arterial  system,  the  clot  will  wax  larger  and  larger ; 
with  the  result  of  ultimately  squeezing  the  life  out  of  the 
medulla — and  with  that  the  existence  of  the  individual 
will  terminate.  The  only  method  of  doing  this  is  to  bleed 
the  patient  within  an  ace  of  his  life ;  for  he  cannot  pos- 
sibly be  in  any  greater  danger  from  excessive  venesection 
than  he  is  from  the  growing  clot.  In  one  such  case  which 
came  under  my  notice  in  South  Wales,  moderate  bleed- 
ing was  tried  ;  but  without  avail.  It  must  be  carried  out 
intelligently  and  heroically.  Nothing  else  offers  even  a 
prospect  of  success.  The  pressure  within  the  cerebral 
artery  must  be  reduced  to  a  level  with  the  resistance 
offered  by  the  contents  of  the  cranium ;  otherwise  the 
clot  must  necessarily  wax  larger.  The  patient  can  but 
die. 

The  patient  developing  chronic  bronchitis  will  tell  of 
the  bulk  of  urine  falling  off  since  the  bronchitis  came  on. 
What  information  does  that  item  afford  us  ?  It  tells,  in 
unmistakable  accents,  that  the  right  ventricle  is  embar- 
rassed. Percussion  can  elicit  nothing.  Emphysematous 
lung  more  or  less  completely  covers  the  heart  ;  perhaps  it 
is  impossible  to  make  out  any  cardiac  dulness  worth  the 
name.  Physical  examination  is  dumb.  There  are  ossified 
costal  cartilages,  rigid  and  resisting ;  and,  behind  them, 
distended  emphysematous  lung-borders  ;  how  can  we  get 
at  the  condition  of  the  right  ventricle  ?  Possibly  by  aus- 
cultation ;  a  disproportion  may  be  discovered  betwixt  the 
first  sound  of  the  heart,  and  the  pulse  at  the  wrist.  The 
large  right  ventricle  furnishes  a  good  first  sound,  audible 
even  through  the  rarified  lung-tissue — a  bad  conductor  of 
sound.     While  the  left  ventricle  sends  on  such  an  amount 


ADVANCED  STAGE.  143 

of  blood  as  comes  over  to  it  from  the  right  heart,  i.e.,  but 
a  small  quantity,  not  producing  much  distension  of  the 
arterial  system.  Still  that  is  not  very  valid  evidence. 
But  if  the  fall  in  the  bulk  of  urine  be  such  as  to  attract 
the  patient's  attention,  and  he  speaks  confidently,  it  tells, 
in  no  broken  accents,  as  to  the  condition  of  the  right 
ventricle. 

And  here  a  short  digression  seems  desirable  for  the 
sake  of  junior  readers.  At  the  hospital  great  reliance  is 
placed  on  physical  examination  ;  and  little  on  statements 
made  by  the  patients,  or  their  friends.  The  class  of  per- 
sons who  are  encountered  at  a  hospital  consists,  in  the 
main,  of  people  who  have  had  something  else  to  do  in  this 
world  than  minutely  note  their  subjective  sensations  ; 
their  attention  has  been  called  elsewhere  by  the  exigencies 
of  their  situation.  If  they  have  noted  them  they  lack 
language  in  which  they  can  express  themselves  precisely. 
Probably,  too,  they  have  not  studied  accuracy,  or  precision 
in  description,  as  a  habit  of  life ;  and  so  mislead  or  give 
incorrect  answers,  without  designing  to  do  anything  of  the 
kind.  No  one  who  has  had  much  experience  in  a  hospital 
is  likely  to  challenge  this  statement.  When  the  ex- 
student  or  hospital  resident  encounters  private  patients, 
he  finds  to  a  large  extent  a  very  different  class.  First  of 
all  they  are  better  educated,  and  can  express  themselves 
correctly  ;  and  often  fluently.  Many  have  not  had  to  work 
for  a  living,  and,  having  no  great  calls  upon  their  attention, 
have  studied  themselves,  and  their  feelings,  minutely.  A 
number,  too,  have  been  more  or  less  invalids  ;  and  have 
preserved  a  careful  record  of  their  experiences.  Fishing 
the  seas  of  the  patient's  sensations  is  very  unprofitable 
with  hospital-patients ;  but  in  the  case  of  an  intelligent 


144  VASO-RENAL  CHANGE. 

private  patient  it  is  far  different  ;  and  the  most  valuable 
information  may  often  be  volunteered,  or  elicited  by  dint 
of  careful  questioning  ;  and  sometimes  cross-examination. 
A  mine  of  matter,  indeed,  can  often  be  found  with  patient 
persistence.  And  this  applies  especially  to  the  intelligent 
lady  who  is  often  the  victim  of  some  outcome  of  vaso- 
renal change.  But  there  is  much  in  the  manner  of  putting 
questions  to  such  a  patient.  She  has  a  highly  developed 
nervous  system,  and  is  remarkably  acute;  so  that  she  will 
perceive  the  drift  of  any  interrogation  at  once,  almost 
before  the  last  word-  is  spoken.  If  she  observes  that  the 
questions  hang  together,  she  will  give  willing  aid  to  the 
questioner.  If  her  conclusions  be  unfavourable,  the  well- 
spring  of  information  will  dry  up  promptly.  If  the  ques- 
tioner can  so  put  his  questions  as  to  reveal  his  thorough 
acquaintance  with  the  subject,  he  gains  her  confidence 
forthwith.  But  if  they  but  betray  unfamiliarity  with  her 
malady,  or  complaint ;  and  give  her  the  impression  that 
they  are  no  more  than  curiosity,  she  will  as  certainly  with- 
hold her  confidence.  For  instance,  we  have  seen  that  vesi- 
cal irritability  is  a  common  accompaniment  of  migraine  ; 
whether  in  its  complete,  or  its  larval  form.  Now,  if  a  com- 
paratively young  man  has  to  make  such  an  inquiry  of  a 
sensitive  lady,  everything  almost  will  turn  on  the  manner 
in  which  the  question  is  asked.  If  it  is  made  in  such  a 
manner  as  to  convey  the  impression  that  it  is  a  matter  on 
which  an  affirmative  answer  is  expected,  and  looked  for ; 
it  at  once  strikes  her  forcibly  as  something  linked  with 
the  other  phenomena.  If  asked  in  an  unfortunate  manner, 
it  will  be  regarded  as  simply  impertinent  ;  and  as  such  be 
resented — and  promptly. 

Nothing  impresses  the  patient  so  profoundly  as  a  series 


ADVANCED  STAGE.  145 

of  well-planted  questions,  like  arrows  in  succession  striking 
the  target.  It  is  quite  natural  that  this  should  be  so. 
The  questions  tell  of  familiarity  with  the  general  condition; 
while  questions  which  fly  wide  of  the  mark  soon  arouse 
the  patient's  suspicions.  An  acquaintance  with  the  general 
condition  of  elderly  patients  will  and  can  alone  enable  the 
medical  man  to  show  his  grasp  of  the  case  in  its  entirety. 

An  illustration  of  what  is  meant  is  furnished  by  the 
following  experience.  Talking  on  matters  medical  to 
the  lad)-  friend  of  an  old  patient,  the  writer  used  the 
expression :  '  The  Almighty  writes  a  legible  hand  when 
once  we  have  learned  to  read  it.' 

The  lady  said,  '  What  do  you  mean  ?' 

Gazing  steadily  at  the  bright  neurotic,  he  asked : 
'  Madam,  have  you  pain  at  one  side  of  your  head,  and 
in  the  eye  at  times,  with  sparks  of  light?' 

The  reply  was  in  the  affirmative. 

'  And  have  you  indigestion  ?' 

'  Yes  !' 

'  With  acidity  and  flatulence  ?' 

Again,  '  Yes.' 

He  then  proceeded  :  '  I  will  tell  you  something.  You 
have  great  irritability  of  the  bladder  with  the  headache.' 

The  lady  looked  much  surprised,  but  replied  firmly : 
'  Yes,  I  have.' 

'  Now,  madam,'  he  continued,  '  I  will  tell  you  something 
more.     You  have  sediments  in  your  water.' 

Perceiving  that  the  speaker  was  perfectly  familiar  with 
his  topic,  she  answered  :  '  Yes,  I  have  that,  too.' 

He  then  went  on :  '  Now,  madam,  do  you  understand 
what  is  meant  by  the  expression,  "  The  Almighty  writes 
a  legible  hand  when  we  learn  to  read  it  "  ?' 

10 


146  VASO-RENAL  CHANGE. 

The  lady  understood  perfectly  after  that.  She  then 
gave  an  account  of  other  members  of  the  family,  who  also 
suffered  from  migraine. 

Now  the  manner  in  which  these  remarks  were  said, 
made  all  the  difference  betwixt  a  very  aggravated  form  of 
impudence,  and  an  interesting  conversation  devoid  of 
offence ;  and  making  a  strong  impression  upon  the  lady's 
mind. 

Then  another  matter  relates  to  prognosis.  A  great 
difference  exists  betwixt  private  and  hospital  patients  as 
to  their  hold  of  life.  The  hospital  patient  has  (probably) 
suffered  from  privation,  led  a  hard  life,  very  often  an 
irregular  life ;  there  is  often  a  history  of  both  alcohol  and 
syphilis — two  highly  important  matters  in  prognosis — so 
that  his,  or  her  hold  on  life  is  greatly  weakened ;  and  the 
system  easily  succumbs.  On  the  other  hand,  the  private 
patient  is  often  (of  course  not  invariably)  a  person  belong- 
ing to  a  long-lived  family,  a  person  of  regular  habits  and 
abstemious  ways ;  quite  a  contrast  to  the  other.  The 
one,  in  short,  has  a  'broken  constitution;'  the  other  has 
a  '  sound  constitution.'  In  each  may  be  found  a  large 
heart,  a  hard  artery,  with  albuminuria  and  tube-casts. 
But  the  two  are  not  on  a  par :  far  from  it !  The  prog- 
nosis in  the  one  is  readily  made  out,  but  in  the  other,  it  is 
very  easy  to  trip.  Further,  errors  in  prognosis  are  apt  to  be 
remembered  to  the  doctor's  detriment ;  and  the  man  who 
survives  a  gloomy  prognosis — and  in  doing  so  disproves 
it — is  apt  to  be  given  to  talk  about  the  subject.  Indeed, 
many  persons  exult  in  recounting  '  how  they  deceived  the 
doctor.'  Sir  Andrew  Clark,  M.D.,  has  uttered  many  a 
vigorous  sentence  of  epigrammatic  character,  but  never  a 
better  one   than   this :    '  Do    not    apply  to  your   private 


ADVANCED  STAGE.  147 

patient  at  the  beginning  of  his  disease  the  prognosis 
which  is  correct  enough  in  the  case  of  a  hospital  patient 
at  the  end  of  his.'  And  above  all  things,  do  not  be  led 
into  the  temptation  of  fixing  the  span  of  life.  This  is  like 
a  besetting  sin  with  some  men ;  and  is  usually  a  most 
dangerous  practice  for  their  reputations.  Of  all  forms  of 
mistake,  the  most  gratuitous  of  all  is — prophecy !  Of 
•course  there  are  times  and  circumstances  when  the 
attempt  must  be  made  ;  but  it  should  always  be  done  with 
considerable  reserve.  '  Fools  rush  in  where  angels  fear  to 
tread,'  certainly  applies  to  a  time-prognosis  in  a  patient's 
bedroom  very  often. 

After  this  digression  the  strictly  medical  aspect  of  the 
subject  may  be  resumed. 

Lead. — The  relations  of  saturnine  intoxication  to  gout 
has  been  a  matter  of  observation  for  more  than  a  century. 
Persons  of  the  uric  acid  diathesis  are  peculiarly  sensitive 
to  lead  ;  while  persons  who  absorb  lead  are  specially  liable 
to  the  uric  acid  formation.  A  foreman  workman,  whose 
special  business  it  was  to  mix  paints,  had  very  curiously 
deformed  hands  and  feet  from  the  deposits  of  lithates  ; 
furnishing  a  striking  example  of  the  relations  of  lead  to 
gout. 

Sauvages  described  '  lead  arthralgia.'  Dr.  Parry,  in 
1807,  spoke  of  'Gout  from  Lead.'  Dr.  Garrod  observed 
the  effect  of  lead  in  diminishing  the  output  of  uric  acid. 
His  conclusion  is  as  follows  :  '  It  would  appear,  therefore, 
that  in  individuals  impregnated  with  lead,  the  blood 
becomes  loaded  with  uric  acid ;  not  from  its  increased 
formation,  but  from  its  imperfect  excretion ;  and  this  is  of 
much  interest  in  connection  with  the  fact  that  the  subjects 
of  lead-poisoning  are  ceteris  paribus,  more  liable  to    be 

10 — 2 


148  VASO-RENAL  CHANGE. 

affected  with  gout ;  and  as  we  shall  see  further  on,  that 
those  who  inherit  the  gouty  diathesis  are  more  likely  to 
become  poisoned  by  the  imbibition  of  lead.'  The  adminis- 
tration of  lead  to  animals  for  some  length  of  time  sets  up 
interstitial  nephritis  of  a  progressive  character. 

It  will  often  then  be  a  desirable  matter  to  look  at  the 
patient's  gums.  If  the  blue  line  be  present  it  speaks  for 
itself.  It  is  less  conspicuous  when  the  gum  is  retracted ; 
but  this  last  fact  has  got  a  significance  of  its  own. 

Advanced  Stage. — As  pointed  out  at  the  end  of  the  last 
chapter,  the  middle  stage  is  completed  sooner  with  some 
persons,  and  in  some  families,  than  in  others.  Sometimes 
this  stage  is  prematurely  brought  to  a  close  by  some 
illness.  Exposure  to  weather  may  start  up  bronchitis,  or 
severe  sciatica,  giving  the  constitution  a  shake.  One 
case  is  well  known  to  me  in  a  hale  medical  man  of  fifty- 
eight,  belonging  to  a  hardy  race  which  made  old  bones, 
who  caught  typhoid  fever,  but  was  not  laid  up,  or  would 
not  lay  off  work  for  it.  This  seemed  to  give  a  terrible 
impetus  to  the  senile  changes  on  foot  ;  and  instead  of 
living  fifteen  years  longer,  as  looked  very  likely,  the 
spring  ran  down  in  thirteen  months.  A  secondary  serous 
inflammation  may  mark  an  epoch  in  the  life  of  an 
individual.  A  not  unusual  expression  used  about  a  man 
after  a  serious  illness  is  this,  '  How  it  has  aged  him,'  and 
especially  when  the  person  is  past  middle  age.  It  may 
be  mental  worry  or  much  affliction ;  but  the  result  is  the 
same — the  spring  runs  down  apace.  In  some  others  who 
are  wearing  well,  and  looking  younger  than  their  real 
years,  the  illness  will  bring  their  appearance  on  and  up  to 
their  actual  years  ;  after  which  they  proceed  at  the  usual 
and  normal  rate. 


ADVANCED  STAGE.  149 

'  A  man  is  as  old  as  his  arteries,'  is  a  French  expression 
often  quoted  by  Dr.  S.  Wilks.  And  it  is  certainly  so. 
No  matter  how  youthful  the  other  tissues,  if  the  arteries  are 
in  an  advanced  stage,  life  is  thereatened  by  arterial  rupture 
on  effort,  or  rise  in  arterial  tension.  The  cases  of  sudden 
death,  now  so  constantly  attributed  to  '  heart  disease,' 
are,  in  a  large  number  of  cases,  rupture  of  a  diseased 
artery,  with  or  without  a  pre-existing  aneurism.  (The 
present  fashion  of  attributing  sudden  death  to  heart 
disease  reminds  one  of  the  habit  of  attributing  sudden 
deaths  to  apoplexy  before  the  diseases  of  the  heart  were 
known.)  The  effect  of  syphilis  upon  arterial  change  must 
be  borne  in  mind,  with  its  tendency  to  thicken  the  arterial 
inner  coat  {tunica  intima).  Such  rupture  may  not  always 
be  due  to  effort :  but  at  times  to  some  arterial  spasm 
raising  the  blood-pressure  in  the  arteries.  Rupture  of  an 
artery  is  certainly  linked  with  sudden  spells  of  cold 
weather. 

Changes  in  the  Vascular  System. — As  years  wear  on,  the 
danger  of  life  from  alterations  in  the  vascular  system 
increases  steadily.  The  large  heart  may  burst  a  brittle 
artery,  and  often  does.  These  are  the  rocks  of  Scylla. 
But  beyond  this  risk,  lies  the  deadlier  terminal  danger 
— the  shoals  of  Charybdis,  viz.,  '  fatty  degeneration  of  the 
heart-wall ;'  the  last  act  in  this  long  pathological  drama. 
Its  march  may  be  slow ;  it  may  give  little  or  no  sign  ; 
like  the  avenging  deities,  its  feet  may  be  shod  with  wool ; 
its  oncome  may  be  insidious ;  but  it  will  be  present  in 
time,  sooner  or  later, — if  the  individual  do  not  die  in  the 
meantime  of  something  else.  There  is  no  escape  from  its 
clutches. 

While    making  this    statement    I    wish    to    express    as 


i3o  V A  SO-RENAL  CHANGE. 

distinctly,  as  forcibly,  and  as  unmistakably  as  lies  in  my 
power,    that   while    fatty   degeneration  of   the    heart,    as 
ordinarily  understood,  is  a  mortal  disease,  it  is  essentially 
a  senile  change  ;  and    indeed    the  last    act  of  this   long 
pathological  process.     As  a  matter  of  strict  pathological 
fact  it  is  found  after  severe  pyrexiae  in  an  acute  form,  or 
pernicious  anaemia  or  phosphorus   poisoning  ;    but,  as   a 
great  clinical  fact,  it  is  associated  with  the  gradual  failure 
of  the  once  large  heart  of  the  vaso-renal  change  ;  and,  as 
such,  has  its  morbid  kith  and  kin,  and  its  own  pathological 
associations.     And  without  these,  the  diagnosis  of  fatty 
degeneration   is   as   cruel   as  it   is  unwarrantable   by  the 
clinical  facts.     A   heart  may  have  but  a  feeble  impulse, 
and  a  weak  first  sound,  and  be   in  an  ill-nourished  and 
flabby   condition,    like    any   other  ill-fed  muscle  ;  but    to 
apply  the  term  '  fatty  degeneration  '  to  such  a  state,  is 
often  simply  diagnostic  slovenliness.     When  the  atheroma- 
tous change  in  the  arteries  is  advanced,  the  change  involves 
the  vessels  of  the  coronary  circulation  ;  and  then  the  fate 
of  the  big  heart  is  sealed.     The  atheromatous  change  is 
often   more   pronounced    in    the    coronary   arteries   than 
elsewhere.     They  are  forcibly  distended  by  exposure  to 
the  aortic  recoil  (the  old  view),  or  to  the  cardiac  systole 
(the  view  now  accepted).     But,   all  the   same,   I    would 
remind  the  reader  the  diagnosis  can  only  be  made  in  the 
post-mortem  room ;  there  is  no  infallible  evidence  in  life  ; 
at  best  it  is  but  a  suspicion, — though  at  times  no  doubt  the 
suspicion  is  very  strong  indeed,  and  all  but  unavoidable. 
Nevertheless  the  term  ought  to  be  restricted  to  the  dead- 
house  whence  it  originally  emerged.     The  term,  indeed, 
is  one  of  those  left-handed  services  which  pathology  has 
rendered  to  clinical  medicine ;  it  had  a  certain  fascination 


ADVANCED  STAGE.  151 

about  it  ;  it  was  used  when  the  causation  of  fatty  degenera- 
tion was  unrevealed  to  us  ;  it  was  recklessly  misapplied, 
and  has  been  the  source  of  incalculable  human  misery  of 
avoidable  nature.  It  has  been  indeed  the  cause  of  measure- 
less unhappiness  from  its  misuse. 

In  order  to  have  clear  views  about  fatty  degeneration, 
a  glance  at  the  subject  historically  will  be  desirable. 
Laennec  distinguished  between  fatty  infiltration  and  fatty 
degeneration  of  the  muscular  fibre  of  the  heart.  The 
facts  remained  with  very  little  advance  made  until 
Rokitanski  took  the  subject  up.  In  1848,  Sir  Thomas 
Watson  says  of  fatty  degeneration,  '  Walls  thus  soft  are 
liable  to  yield  under  pressure  ;  but  I  know  of  no  particular 
symptom  by  which  we  can  detect  such  a  state  of  soften- 
ing.' Yet  forthwith  the  profession,  and  especially  the 
less  competent  members  of  it,  began  to  make  the 
diagnosis  of  a  disease  of  which  no  symptom  in  life  was 
recognisable  ;  according  to  one  of  the  best  observers  who 
ever  stood  in  the  front  rank  of  the  profession.  Great 
quietude  of  mind  and  body  was  thought  essential  to 
existence  ;  and  within  my  recollection  men,  advanced  in 
years,  walked  about  with  the  utmost  circumspection, 
afraid  of  shock  or  fall,  where  the  diagnosis  of  '  fatty 
degeneration  '  had  been  made  by  some  one  who  knew 
little  more  of  the  disease  than  its  name.  (Dr.  Fred. 
Roberts  informs  me  that  this  kind  of  diagnosis  is  not  yet 
extinct.)  The  impression  upon  the  minds  of  the  profes- 
sion seem  to  have  been  something  like  this  :  '  The  muscular 
structure  of  the  heart  is  liable  to  degenerate  into  fatty 
debris  (that  had  been  fully  demonstrated  by  several 
observers,  especially  Dr.  Omerod),  but  under  what 
circumstances   was    unknown  ;  but    the    belief  seems   to 


152  V A  SO-RENAL  CHANGE. 

have  been  that  it  was  an  idiopathic  decay  of  the  heart- 
wall  of  mysterious  and  unknown  origin.  Any  view  more 
calculated  to  sow  unhappiness  and  misery  in  the  human 
breast  it  is  impossible  to  conceive.  And  right  and  left 
men  set  to  work  to  diagnose  fatty  degeneration  of  the 
heart  in  the  most  reckless  manner.*  A  feeble  impulse 
and  a  faint  first  sound ;  and  the  diagnosis  was  made. 
One  lady  has  told  me  of  such  a  diagnosis  being  made  in 
her  husband's  case  thirty  years  ago,  and  of  her  being 
told  '  never  to  leave  him,  as  he  might  die  at  any  moment  ' 
(though  how  her  being  beside  him  was  to  affect  the 
result  is  not  very  apparent)  ;  the  said  husband  being  at 
the  present  time  a  hale  man  without  the  slightest  evidence 
of  any  weakness  about  his  heart.  This  is  only  one 
solitary  instance  out  of  many  ;  and  for  a  quarter  of  a 
century  medical  men  went  on  in  this  fashion  causing 
untold,  incalculable  misery;  and  in  the  end  discrediting 
their  own  reputations.  When  Dr.  Walshe  brought  out 
his  work  in  1851,  he  gave  an  indistinct  apex  beat,  '  a 
feeble  toneless  first  sound,'  infrequent  or  irregular  pulse, 
incapacity  for  exertion,  fits  of  dyspnoea,  angina  more 
or  less  perfect,  a  tendency  to  syncope,  and  vertigo,  as  its 
main  indications.  He  also  wrote,  '  Fatty  disorganization 
of  the  heart  is  by  no  means  necessarily  fatal.  I  have 
known  extensive  destruction  of  the  kind  exist,  where 
death  has  occurred  from  unconnected  chronic  diseases  of 
other  organs.'  All  which  tell  that  by  that  time  some  real 
knowledge  was  being  acquired  on  the  subject. 

Rokitanski  first  put  the  actual   pathology  of  fatty  de- 
generation  on  a  sound  basis.     He  noted  its  association 

9  Just  as  they  did  '  an  atheromatous  state  of  the  cerebral  arteries 
when  the  phrase  came  into  use. 


ADVANCED  STAGE.  153 

with  'ossification  of  the  coronary  arteries,'  and  also  that 
it  '  occurs  more  especially  in  hypertrophied  and  dilated 
hearts.'  He  describes  it  as  presenting  many  centres 
scattered  throughout  the  heart  substance ;  where  '  the 
muscular  substance  is  pale,  flaccid,  of  a  dirty -yellow  colour, 
and  soft  and  friable  ;'  while  '  a  microscopic  examination 
shows  an  accumulation  of  black  and  dark  outlined 
globules,  which  prove  to  be  fat ;  while  the  muscular  fibres 
are  found  to  have  lost  their  striated  appearance,  and  the 
fibrillse  are  soft,  and  readily  break  down  into  delicate 
molecules.'  Again,  he  refers  to  its  association  with  the 
enlarged  heart  :  '  This  form  of  adiposity  most  commonly 
occurs  in  the  muscular  substance  of  the  left  ventricle, 
and  in  cases  of  hypertrophy.'  So  that  already  fatty  de- 
generation is  looming  up  as  the  end  of  the  large  heart. 
He  also  remarks  that  rupture  of  the  softened  heart-wall 
by  laceration,  though  it  might  be  supposed  to  be  frequent, 
yet  '  such  is  very  rarely  the  case.' 

When  Dr.  Stokes  of  Dublin  brought  out  his  classical 
work  on  the  'Diseases  of  the  Heart,'  he  discussed  the 
subject  at  considerable  length ;  accepting  Rokitanski's 
description  of  its  pathology.  The  association  of  the 
necrobiotic  change  with  an  atheromatous  aorta  begins  to 
gleam  through  the  recorded  cases  he  gives  ;  and  there- 
fore we  are  not  surprised  at  the  following  being  among 
his  conclusions.  It  is  associated  with  '  hepatic  or  renal 
disease  ;  and,  lastly,  atheromatous  alterations  of  the 
aorta.  That,  though  often  associated  with  the  gouty 
state,  it  may  occur  independently  of  that  condition.  That 
the  disease  may,  on  the  one  hand,  affect  a  heart  already 
in  a  state  of  hypertrophy ;  or,  on  the  other,  of  atrophy. 
That  in  the  earlier  stages  but  little  change  is  apparent  to 


154  VA SO-RENAL  CHANGE. 

the  unassisted  eye  in  the  anatomical  condition  of  the 
ventricle  ;  and  it  is  by  microscopical  examination  alone 
that  we  can  determine  the  actual  freedom  of  the  organ 
from  disease.' 

Here  is  one  of  the  ablest  physicians  who  ever  breathed, 
stating  in  unmistakable  language  that  microscopical  ex- 
amination of  the  structure  of  the  heart  alone  could  deter- 
mine the  presence  or  absence  of  fatty  degeneration  of  the 
muscular  structure  of  the  heart ;  while  on  all  sides  men  of 
ordinary  parts,  and  by  no  means  remarkable  either  for 
their  clinical  acumen  or  their  familiarity  with  pathology, 
were  making  the  diagnosis  in  an  off-hand  fashion ;  scatter- 
ing misery  and  unhappiness  broadcast  over  the  land.  It 
is  no  uncommon  experience  to  find  a  patient  telling  that 
so  many  years  ago  his  heart  was  pronounced  to  be  in  a 
state  of  fatty  degeneration;  a  diagnosis  utterly  unjusti- 
fiable— and  disproved  by  the  subsequent  history  of  the 
individual. 

When  about  it,  it  may  be  well  to  thrash  this  matter  out 
thoroughly;  and  knock  the  brains  out  of  the  demoralizing 
superstition  that  fatty  degeneration  of  the  heart  is  an 
idiopathic  disease  of  muscle  of  mysterious  origin  ;  spring- 
ing up  like  a  thief  in  the  night ;  slaying  its  victim  without 
giving  a  hint  of  its  presence  :  the  dread  and  terror — the 
ghastly  spectre  of  hundreds  of  unfortunate  persons,  who 
have  been  told  by  their -medical  advisers  that  they  have 
fatty  degeneration  of  the  heart ;  or  have  made  the  diagnosis 
for  themselves  by  dipping  into  medical  literature  of  a  date 
anterior  to  fairly  full  acquaintance  with  the  disease.  What 
says  Dr.  Da  Costa  in  his  unparalleled  work  on  '  Medical 
Diagnosis  '  (1881)  ?     He  puts  the  matter  thus  : 

'  Fatty  Degeneration. — Our  power  to  recognise  the  fatty 


ADVANCED  STAGE.  155 

changes  during  life  has  not  kept  pace  with  our  power  to 
recognise  it  after  death.  There  is  as  yet  no  sign  dis- 
covered by  which  we  can  positively  say  the  dangerous 
disorganization  of  the  muscular  fibre  of  the  heart  is  in 
progress.  We  may,  however,  suspect  it  if  the  signs  of 
weak  action  of  the  heart — feeble  impulse  and  ill-defined 
sounds — coexist  with  oppression,  with  tendency  to  cold- 
ness of  the  extremities,  with  a  pulse  preternaturally  slow 
or  permanently  frequent  and  irregular,  and  be  met  in 
a  person  who  is  the  subject  of  gout,  or  of  a  wasting 
disease,  or  is  very  intemperate,  or  has  arrived  at  a  time 
of  life  at  which  all  the  organs  are  prone  to  undergo  decay. 
Sometimes  more  than  a  suspicion  is  warranted  if,  in 
addition  to  these,  there  be  proof  of  atheromatous  changes 
in  the  vessels,  or  of  fatty  degeneration  elsewhere,  such  as 
an  circus  senilis;  or  if  it  be  ascertained  that  the  patient 
suffers  from  severe  pain  across  the  upper  part  of  the 
sternum,  and  from  paroxysms  of  severe  pain  in  the 
heart  ;*  that  he  sighs  frequently ;  that  he  is  easily  put 
out  of  breath ;  that  his  skin  has  a  yellow,  greasy  look  ; 
that  he  is  subject  to  syncope,  or  to  seizures  during  which 
his  respirations  come  to  a  standstill ;  and  that  he  is  liable 
to  vertigo,  or  to  be  stricken  down,  with  repeated  attacks 
having  the  character  of  apoplexy,  save  that  they  are  not 
followed  by  paralysis.' 

Such,  then,  are  the  clinical  features  of  fatty  degenera- 
tion of  the  heart.  It  is  found  with  other  evidences  of 
senile  decay  ;  and  usually  with  failing  hypertrophy. 

The  external  appearance  of  the  heart  is  as  follows — the 

s  My  own  impression  is  that  the  agonizing  pain  of  angina  is  due 
to  the  distension  of  the  aortic  root,  rather  than  actually  in  the  heart 
itself. 


156  VA SO-RENAL  CHANGE. 

description  having  been  written  while  frequenting  the 
Pathological  Institute  of  Vienna :  '  The  process  does  not 
pass  on  by  continuity  from  one  muscular  bundle  to 
another,  or  even  from  one  fibril  to  another  in  a  bundle, 
but  is  irregular ;  and  side  by  side  may  be  seen  fibres  in 
all  conditions;  from  the  still  normal  to  the  most  advanced 
condition,  with  fibrils  in  various  stages  among  them.  The 
colour  of  the  heart  has  become  paler,  and  of  a  dirty 
yellow,  or  of  a  "dead-leaf"  colour,  somewhat  unevenly 
though,  and  some  parts  are  paler  than  others.  The  con- 
sistence is  altered,  the  wall  breaks  down  readily  under 
the  finger,  and  in  advanced  cases  a  finger  may  be  pushed 
through  the  ventricular  wall  as  through  one  or  two  thick- 
nesses of  wetted  paper.  The  tissue  is  pliable,  and  tears 
with  a  sort  of  fracture,  and  crumbles  down  under  the 
finger  and  thumb.  It  feels  greasy  and  unlike  normal 
heart-wall,  and  a  warm  knife  passed  through  it  looks 
oily.  There  is  not  necessarily  any  change  in  bulk,  nor 
does  the  degenerate  structure  take  on  dilatation  inevit- 
ably. The  changes  may  be  localized  and  confined  to 
some  particular  portion,  especially  when  due  to  disease 
of  the  coronary  arteries.*  This  may  give  a  mottled 
appearance  to  the  heart ;  but,  as  commonly  and  more  so, 
the  heart  is  generally  of  this  pale  buff-colour,  the  blue 
coronary  veins  looking  marked  and  distinct.  The  coronary 
arteries  are  not  uncommonly  tortuous,  rigid,  and  athe- 
romatous. The  whole  appearance  in  a  well-marked  case 
is  that  of  degeneration,  of  partial  death,  or  imperfectly 
renewed  life,  which  is  quite  borne  out  by  the  microscopic 
appearances.'     Sometimes  the  necrobiotic  change  is  most 

°   In  the  great  hospital  of  Vienna  soft  hearts  were  common  as  the 
result  of  pyrexia,  puerperal  and  other. 


ADVANCED  STAGE. 


157 


marked  under  the  endocardium,  the  external  muscular 
layers  being  comparatively  unaffected.  '  To  understand 
why  the  inner  layers  should  especially  suffer,  we  must 
remember  that  the  innermost  layers  of  the  heart  are 
farthest  from  the  coronary  arteries,  and  that  they  are 
broken  up  into  columned  camece,  a  condition  which  limits 
the  directions  of  vascular  supply  to  the  attached  ends  of 
the  columns,  so  that  one  perceives  that  these  inner  layers 
are  under  comparative  difficulties  in  obtaining  nourish- 
ment, which  may  explain  the  frequency  with  which  this 
fatty  degeneration  occurs  in  and  is  limited  to  them.' 
(Wicks  and  Moxon's  '  Pathological  Anatomy.')  When  the 
heart  as  a  whole  is  ill-nourished,  the  parts  whose  blood- 
supply  is  least  abundant  will  naturally  suffer  most. 

The  condition  of  the  walls  of  the  coronary  arteries  and 
their  branches  is  that  of  thickening,  and  diminution  of  the 
bore,  or  calibre;  by  which  the  blood-current  through  them 
is  distinctly  lessened.     In  the  accompanying  illustration 


Fig.  17.— Transverse  Section  of  two  Small  Arteries.     Magnification, 
300  diameters. 


this  is  well  seen.  A  is  a  normal  artery;  while  B  is  an 
artery  of  the  same  size,  which  has  undergone  athero- 
matous change.  It  is  easy  to  recognise  at  a  glance  the 
profound   effect    such   a   reduction   of   the   blood-stream 


158  VASO-REXAL  CHANGE. 

must  exercise  over  the  nutrition  of  the  tissues ;    which 
derive  their  blood-supply  from  this  altered  vessel. 

Muscular  fibre  is  a  somewhat  loose  combination  of 
albumen  and  fat ;  and  when  its  blood-supply  is  cut  down, 
it  breaks  asunder  into  fat,  and  some  nitrogenized  body 
which  finds  its  way  into  such  blood-current  as  remains ; 
or  is  absorbed  in  some  way  as  yet  unknown  to  us.  The 
nitrogenized  factor  certainly  gets  away,  leaving  the  fat. 
Such,  indeed,  is  the  physiological  involution  of  the  uterus 
after  the  expulsion  of  its  contents  in  parturition.     The 


<®3 

Fig.  18. — Fibres  of  Heart  Muscle  stained  with  Osmic  Acid,  from  a  case 
of  fatty  degeneration  of  the  organ  resulting  from  coronary  sclerosis- 

a,  Early  stage,  stain  very   indistinct,   very   fine   molecules  of  fat. 

b,  More  advanced,  from  the  same  specimen  ;  strictures  in  places 
altogether  disappeared  ;  granules  of  fat  of  very  varying  size  stained 
black  by  the  osmic  acid.     Magnification,  300  diameters. 

first  effect  of  this  interference  with  the  nutritive  blood- 
current  is  that  the  ill-fed  muscular  fibrillar  of  the  heart- 
wall  begin  to  lose  their  striae  ;  which  first  become  indis- 
tinct, and  then  disappear. 

Such  a  muscular  fibre  in  a  comparatively  early  stage  is 
seen  in  the  fibre  A  in  the  accompanying  illustration ;  while 
B  is  a  fibre  in  a  more  advanced  condition,  which  has 
indeed  no  longer  any  claim  to  be  regarded  as  muscle. 
When  the  muscular  structure  of  the  heart  is  pervaded  by 
this  necrobiotic  change  it  is  softened,  and  has  a  tendency 


ADVANCED  STAGE.  159 

to  yield  ;  so  that  the  once  concentrically,  or  purely  hyper- 
trophied  heart  dilates  ;  and  a  condition  of  mixed  hyper- 
trophy and  dilatation  is  established;  which  distinctly  lowers 
the  heart's  energies  and  power.  It  begins  to  fail ;  and  is 
liable  to  be  brought  to  a  standstill  in  diastole  by  any 
demand  upon  it  :  whether  effort,  as  hastening  to  catch  a 
train  ;  or  bv  some  vaso-motor  disturbance,  as  arteriole 
spasm.  A  sudden  rise  in  the  blood-pressure  in  the  arteries 
will  overtax  the  weakened  heart ;  and  such  doubtless  is 
often  the  immediate  cause  of  death  in  persons  whose 
hearts  are  the  seat  of  fatty  degeneration.  Or,  maybe  the 
feeble  heart  is  arrested  by  some  depressant  toxic  agent 
produced  within  the  body  itself.  Dr.  Lauder  Brunton 
holds  that  the  liver,  as  '  a  porter  at  the  gate,'  is  a  filter 
which  normally,  and  in  health,  arrests  the  malign  and 
poisonous  products  of  later  digestion  ;  and  prevents  their 
entering  the  general  circulation.  When  the  liver  is 
impaired  its  action  as  a  filter  is  reduced.  In  old-standing 
cases  of  vaso-renal  change,  and  in  advanced  life,  the  liver 
as  a  filter  fails  in  its  duty  ;  while  the  kidneys  are  the 
seat  of  extensive  cirrhosis,  and  so  are  deficient  in  excre- 
tory power.  No  wonder  then  if,  after  an  unusually  hearty 
meal,  death  occurs  in  sleep  from  the  accumulation  of  toxic 
products  of  digestion  in  the  blood  ;  acting  as  depressants 
of  the  heart's  action. 

But  such  sudden  failure  of  the  heart's  action  is  rather 
the  exception  than  the  rule  ;  the  larger  majority  dying 
slowly  of  gradual  failure  of  the  heart's  power,  due  to  the 
degeneration  and  yielding  of  its  muscular  walls. 

In  the  fatty  degeneration  of  the  muscular  structure  of 
the  heart  owing  to  the  gradual  occlusion  of  the  coronary 
arteries  and  their  branches,  it  is  impossible  to  avoid  some 


160  V A  SO-RENAL  CHANGE. 

speculations  as  to  the  possible  part  syphilis  may  play  in 
producing  the  result.  Syphilis  has  a  tendency  to  thicken 
the  tunica  intima,  as  is  seen  in  p.  95,  and  the  addition  of 
a  syphilitic  element  in  the  vaso-renal  change  may  occlude 
the  coronary  circulation  earlier  than  would  be  the  case  if 
the  atheromatous  changes  had  had  no  such  ally.  It 
is  a  matter  well  worth  investigation  by  pathologists  ;  and 
if  this  should  ultimately  turn  out  to  be  a  well-founded 
surmise,  it  will  add  another  to  the  many  remote  lesions 
which  take  their  origin  in  syphilitic  infection.  At  least 
the  matter  is  one  worthy  of  consideration,  and  investiga- 
tion ;  whatever  may  be  the  conclusions  arrived  at  by 
investigators.  Clinically,  one  encounters  not  uncommonly 
cases  of  vaso-renal  change,  where  there  is  also  a  history 
of  syphilitic  infection  ;  but  a  wider  field  of  observation  is 
essential  to  determine  how  far  a  syphilitic  element  working 
in  the  atheromatous  change,  may  antedate  fatty  degenera- 
tion of  the  heart-wall — from  diminution  of  the  lumen  of 
the  coronary  arteries  and  their  branches. 

We  can  readily  understand  that  the  age  at  which 
atheroma  of  the  coronary  vessels  becomes  so  established 
as  to  lead  to  the  necrosis  of  the  muscular  structure  of  the 
heart,  in  a  hale  and  otherwise  healthy  person  with  a  good 
family  history — is  far  in  advance  of  that  when  death  from 
cardiac  failure  occurs  in  a  person  of  indifferent  family  history 
who  has  acquired  syphilis  early  in  life,  and  who  has 
chronically  indulged  in  alcoholic  excess  ;  and  still  more  if 
to  this  be  added  times  of  privation  and  exposure.  In  this 
latter  case  fatty  degeneration  of  the  heart  may  occur  at  a 
comparatively  early  age. 

Such,  then,  are  the  changes  which  go  on  in  the  structure 
of  the  heart  itself,  while  the  coronary  arteries  are  tortuous, 


ADVANCED  STAGE.  161 

elongated,  and  of  narrowed  calibre  from  the  adventitious 
growth  in  the  tunica  intima.  The  heart  gradually  wanes 
in  power,  the  aorta  becomes  less  elastic  and  more  rigid  ; 
its  recoil  is  diminished,  and  the  general  circulation  is 
languid.  As  to  the  effect  of  the  spread  of  this  necrobiotic 
change  throughout  the  muscular  wall  of  the  heart,  the  late 
Dr.  Hayden  wrote :  '  This  is  no  doubt  most  commonly 
the  immediate  cause  of  the  fatal  symptom  when  death 
proceeds  from  the  heart  in  cases  of  hypertrophy  from 
renal  or  valvular  disease,  or  from  atheroma  of  the  aorta. 
When  failure  of  the  heart  in  a  gouty  subject  is  indicated 
by  irregular  action  and  palpitation,  quickly  followed  by 
paroxysmal  dyspnoea,  and  dropsical  effusion  becomes  the 
signal  of  a  'break-up'  of  the  constitution,  as  not 
unfrequently  happens,  fatty  degeneration  and  dilatation  of 
the  heart  will  be  found  the  last  links  of  the  chain,  of  which 
atheromatous  change  of  the  aorta,  hypertrophy  of  the 
heart,  and  granular  degeneration  of  the  kidneys  constitute 
the  preceding  links.' 

As  to  the  rate  at  which  this  disorganization  of  muscular 
fibre  progresses,  it  may  safely  be  said  that  it  varies.  In 
most  cases  the  progress  is  slow — if  it  be  possible  to  speak 
of  a  matter  which  cannot  be  seen,  but  only  calculated — 
and  probably  is  a  matter  of  years.  In  other  cases,  again, 
an  atheromatous  tubercle  of  comparatively  rapid  growth 
blocks  up  one,  or  other  coronary  artery ;  and  the  progress 
of  the  case  is  comparatively  rapid.  Probably  it  is  in  these 
cases  that  sudden  death  takes  place.  In  a  case  of  sudden 
death  under  circumstances  of  excitement  in  an  old  gentle- 
man in  Hyde  Park,  the  autopsy  at  St.  George's  Hospital 
revealed  the  fact  that  an  atheromatous  patch,  so  calcified 
as  to  resemble  a  scale  of  bone,  had  become  loosened,  and 

ii 


1 62  VASO-RENAL  CHANGE. 

dislodged ;  and  had  closed  the  mouth  of  a  coronary  artery 
so  completely  that  sudden  death  was  the  consequence. 
Some  cases  seem  to  march  on  at  a  very  rapid  rate.  Such 
an  one  came  under  my  notice  two  or  three  years  ago.  The 
patient  was  a  well-known  temperance  lecturer ;  who  had 
been  lecturing  with  his  usual  vigour  only  a  very  few  weeks 
before  he  fell  down  in  the  water-closet.  His  medical  man 
and  myself  thought  the  tout  ensemble  of  the  case  looked 
very  like  some  rapid  growth  in  connection  with  the 
coronary  vessels ;  and  warned  him  against  any  exertion,  or 
effort.  He  kept  very  quiet  for  a  week  or  two;  and  felt  so 
well  that  he  began  to  think  that  the  gravity  of  the  case 
was  over-estimated.  He  went  down  to  the  City  to  arrange 
about  a  lecturing  tour,  came  back,  went  into  the  water- 
closet;  and  died  there.  There  was  no  post-mortem.  But 
it  may  be  said,  and  with  truth,  that  in  fatty  degeneration 
sudden  death  is  the  exception  rather  than  the  rule.  Per- 
haps, when  fatty  degeneration  occurs  with  aortic  incom- 
petence, sudden  death  is  frequent.  Where  one  spot  is 
gravely  softened  from  occlusion  of  its  own  nutrient  arterial 
twig,  death  may  take  place  very  suddenly  from  rupture. 

More  commonly  by  far,  the  heart  becomes  gradually 
impaired ;  and  dilates  as  the  softening  progresses. 
Niemeyer,  speaking  of  the  prognosis  of  hypertrophy  of 
the  heart,  wrote :  '  The  prognosis  is  often  rendered  more 
grave  by  the  occurrence  of  a  consecutive  degeneration  of 
the  substance  of  the  heart.  With  the  transition  from 
genuine  to  spurious  hypertrophy,  the  picture  changes,  and 
many  dangers  arise.'  As  long  as  the  nutrition  of.  the 
large  heart  of  vaso-renal  change  is  maintained,  all  is  well. 
But  when  the  patient  becomes  less  equal  to  effort ;  and 
exertion  produces  palpitation  in   a  person  who   has  not 


ADVANCED  STAGE.  163 

suffered  from  these  symptoms  previously;  and  a  condition 
of  hypertrophy  blended  with  dilatation  is  found  on 
physical  examination,  then  we  may  fairly  conclude  that 
fatty  degeneration  is  afoot  throughout  the  muscular  wall 
of  the  heart.  To  follow  Niemeyer :  '  The  symptoms  of 
dilatation  supervening  upon  excentric  hypertrophy,  arising 
from  endarteritis  deformans,  are  essentially  the  same  as 
those  described  above  (Dilatation).  It  is  often  impossible 
to  determine  with  which  of  these  two  forms  we  have  to 
deal.  This  will  not  seem  strange  when  we  consider  that 
endarteritis  deformans  does  not  occasion  any  derange- 
ment of  the  circulation  as  long  as  the  heart  remains  in  a 
state  of  excentric  hypertrophy;  and  that  the  evidence  of 
disease  only  becomes  apparent  after  the  hypertrophy  has 
become  spurious  by  secondary  degeneration,  and  after  its 
compensatory  action  has  become  imperfect.  When  we  find 
by  physical  exploration  that  an  old  person  suffering  from 
cyanosis  and  dropsy  has  a  dilated  heart,  that  his  super- 
ficial arteries  are  tortuous,  pulsate  visibly,  and  feel  hard 
to  the  touch,  the  case  is  probably  one  of  endarteritis 
deformans,  with  secondary  degeneration  of  a  heart  which 
was  once  hypertrophied.' 

As  a  matter  of  clinical  experience,  it  is  not  by  any 
means  always  easy  on  first  seeing  a  patient  advanced  in 
years,  and  undergoing  vaso-renal  change,  to  determine 
whether  it  is  a  condition  of  blended  hypertrophy  with 
dilatation  we  have  to  deal  with — a  case  where  this  com- 
bined condition  has  existed  for  some  time  ;  or  it  is  one  of 
a  once  purely  hypertrophied  heart  beginning  to  yield,  and 
dilate  in  consequence  of  the  spread  of  fatty  degeneration 
throughout  its  walls.  Physical  examination  tells  us  the 
actual  condition  of  hypertrophy  combined  with  dilatation; 

11 — 2 


1 64  VA SO-RENAL  CHANGE. 

but  no  more.  In  order  to  make  at  all  sure  about  the 
state  of  the  heart-wall,  the  patient's  history  must  be  care- 
fully elicited.  If  there  be  no  new  feature,  and  palpitation 
and  shortness  of  breath  on  effort  are  old  experiences;  then 
probably  the  condition  is  one  of  old  standing.  If,  on  the 
other  hand,  the  palpitation  and  dyspnoea  on  effort  are  new 
departures,  and  the  bulk  of  urine  has  decreased  steadily 
for  some  time;  then  the  probability  of  the  dilatation  being 
of  recent  standing  becomes  very  strong, — and  the  case  is 
one  of  failing  hypertrophy. 

A  rats  Senilis. — Evidence  of  degenerative  change  else- 
where is  of  great  value  in  attempting  to  appraise  the  state 
of  the  muscular  wall  cf  a  suspected  heart.  Such  change 
in  the  eye  has  long  been  held  of  diagnostic  and  prognostic 
import ;  and  is  known  as  the  arcus  senilis.  It  consists  of 
a  crescent-shaped,  or  bow-like  line  at  the  junction  of  the 
cornea  and  the  sclerotic ;  seen  on  raising  the  upper  eye- 
lid. Usually  a  like  change  can  be  detected  under  the 
lower  eyelid.  It  takes  place  where  the  eye  is  covered 
from  light  by  the  lid.  Gradually  the  horns  approach 
each  other,  and  then  a  ring  is  formed.  This  trulysenile 
degenerative  change  must  be  distinguished  from  the  ring 
of  lime-salts  which  forms  in  many  persons  advancing  in 
life.  This  bears  some  relation  to  the  ring  of  bony  plates 
found  in  some  birds  in  this  locality — the  line  of  union  of 
the  cornea  and  the  sclerotic.  It  forms  a  ring  (anmthts) 
from  the  first ;  is  equally  marked  in  the  parts  exposed  to 
light,  and  those  covered  by  the  eyelids ;  it  has  a  sharp, 
well-defined  outline ;  while  the  central  portion  of  the 
cornea  is  perfectly  bright  and  clear.  In  the  significant 
form  the  parts  under  the  eyelid  show  the  change  most 
prominently,  even  when  the    horns  of  the   bow    (arcus) 


ADVANCED  STAGE.  165 

meet ;  the  outline  is  hazy  and  blurred  and  ill-defined ; 
while  the  cornea  is  hazy  and  cloudy  from  the  presence  of 
fat-granules  throughout  its  structure.  This  condition  of 
the  eye — true  arcus  senilis — was  well  marked  in  the  case 
of  the  woman  who  died  from  a  dissecting  aneurism 
{p.  97)  ;  and  on  microscopic  examination  of  the  heart- 
muscle  considerable  degeneration  of  the  fibrillar  was 
found  ;  some  fibres  normal,  some  losing  their  striae, 
while  others  again  were  but  a  string  of  oil-beads  within 
the  sarcolemma ;  all  lying  side  by  side.  (This  bears  out 
what  Walshe  said  about  extensive  destruction  of  this  kind 
having  been  found  to  exist,  '  where  death  had  occurred 
from  unconnected  disease  of  other  organs.') 

The  Descent.— As  said  before,  when  degeneration  of  the 
heart-wall  sets  in,  the  case  has  passed  '  the  turn  of  the 
hill ;'  and  commenced  the  descent.  This  descent,  how- 
ever, takes  several  directions.  A  few  illustrative  cases 
will  best  demonstrate  this. 

R.  B.,  an  old  farmer  of  70,  was  seen  by  me  several 
times  a  good  many  years  ago,  but  I  was  not  his  regular 
medical  attendant.  On  one  occasion  he  was  propped  up 
in  bed,  with  his  lower  extremities  very  full  of  water,  ex- 
tending to  his  groins.  His  heart  was  weak,  and  its  action 
irregular.  He  seemed  very  ill,  and  the  look-out  very  dark. 
Nevertheless,  eighteen  months  after  this  he  was  riding 
about  upon  his  pony,  looking  after  his  farm,  and  as  well  as 
most  men  of  his  years.  He  was  continuing  well  when  I 
left  the  neighbourhood. 

T.  G.,  an  old  gentleman  of  87,  was  sitting  in  his  arm- 
chair, unable  to  lie  in  bed,  with  an  aortic  stenosis 
and  much  dropsy  in  both  legs  when  first  seen.  He  was 
put  under  treatment ;  and  after  being  in  his  chair  three 


1 66  VASO-RENAL  CHANGE. 

weeks,  he  could  lie  down  in  bed.  He  got  quite  well  of  his 
drops)' ;  and  resumed  his  usual  habits,  being  apparently 
in  good  health  for  a  man  of  his  advanced  years.  Six 
months  later,  being  sent  for,  he  was  dead  before  my  arrival. 

R.  N.,  a  retired  farmer,  aged  86,  was  also  sitting 
in  his  chair,  unable  to  lie  down,  with  aortic  stenosis  and 
dropsy  in  both  legs,  when  first  seen.  After  a  week  or  two 
he  could  take  to  his  bed.  In  three  or  four  months  he  was 
up  and  about,  and  was  very  active  for  his  years.  Two 
years  later  he  had  a  return  of  his  old  symptoms,  and 
died  ;  but  not  under  my  care,  and  I  can  only  speak 
generally  about  him. 

J.  H.,  aged  69,  a  brewery  man,  was  admitted  into 
the  West  London  Hospital,  January  25,  1877.  He  had 
dropsy  up  to  his  scrotum,  and  also  in  both  arms.  He  had 
mitral  insufficiency,  while  the  aortic  sound  was  muffled. 
Under  treatment  the  bulk  of  urine  rose,  and  the  dropsy 
fell.  On  February  17  he  left  the  hospital,  and  the  house- 
surgeon  wrote  ■  Discharged  cured '  against  his  name. 

Dr.  Cheyne  put  on  record  the  following  case  :  A  gentle- 
man, aged  60,  a  free-liver,  had  gout  in  his  feet,  and 
oedema  in  the  ankles  at  night.  He  took  a  long  walk,  and 
suffered  from  palpitation  after  it.  After  that  he  failed 
generally;  oedema  increased  in  the  limbs  and  extended  to 
the  lungs.  He  died  of  serous  apoplexy.  '  The  heart  was 
three  times  its  natural  size  ;  its  structure  was  extensively 
in  "a  soft,  fatty  condition."  The  valves  were  sound,  and 
the  aorta  studded  with  steatomatous  and  earthy  concre- 
tions.'    (Taken  from  Stokes.) 

The  following  case  is  taken  from  Dr.  Basham's  well- 
known  work  on  'Dropsy':  J.  L.,  set.  50,  was  admitted 
into  the  Westminster  Hospital  for  dropsy,  extending  up 


10 


11 


b  :      - 
■  s*-C§ .- 


W.R  Basham    del 


ADVANCED  STAGE.  167 

the  legs  to  the  genitalia.  The  aspect  of  the  patient  was 
characteristic  of  renal  dropsy.  After  being  six  weeks 
under  treatment,  and  feeling  in  better  health  than  for 
months  past,  the  anasarca  having  entirely  subsided,  he 
requested  to  be  dismissed.  Six  months  later  he  was 
again  admitted,  suffering  in  the  same  way,  but  worse. 
Again  he  improved  to  the  point  of  talking  about  going 
out,  when  he  was  stricken  with  apoplexy,  from  which  he 
died  in  four  hours.  '  An  effusion  of  loosely  coagulated 
blood  was  found  in  the  substance  of  the  pons  Varolii,  from 
which  it  passed  behind  the  medulla  oblongata.  Blood 
was  also  extravasated  into  the  fourth  ventricle.  The 
arteries  at  the  base  of  the  brain  were  opaque  and  rigid, 
the  larger  ones  even  quill-like  ;  some  small  branches  con- 
tiguous to  the  seat  of  the  haemorrhage  were  teased  out  with 
needles,  and  the  microscopic  appearance  is  represented  in 
Fig.  6  of  the  accompanying  plate.  The  heart  was  natural 
in  size,  the  valves  healthy  ;  its  muscular  structure  ap- 
peared paler  than  in  a  well-nourished  heart.  The  kidneys 
were  increased  in  size,  lobulated,  weighing  severally  eight 
and  a  half  and  nine  ounces  ;  in  colour  they  were  of  a  pale 
fleshy  tint.  Post-mortem  observation  showed  that  the 
heart-fibre  and  the  arterial  textures  ultimately  partici- 
pated in  this  fatty  decay.  The  muscular  fibre  of  the  left 
ventricles  of  the  heart  exhibited  traces  of  fatty  degenera- 
tion. The  elastic  coat  of  the  artery  is  altered  by  this 
fatty  deposit ;  it  becomes  easily  torn  and  ruptured,  and 
destructive  haemorrhage  followed.' 

Chronic  Albuminuria. — Connected  with  degeneration  of 
the  arteries  of  the  brain  and  heart-fibre. 

1,  2,  3,  and  4  are  tube-casts  ;  5,  a  section  of  heart-fibre ; 
6,  an  arterial  .twig  from  the  neighbourhood  of  the  blood- 


1 68  VASO-RENAL  CHANGE. 

clot;  7  and  8  are  renal  epithelium;  g,  a  portion  of  the 
cortical  layer  teased  out  with  needles,;  io  is  a  straight 
tube  from  a  cone;  while  n  and  12  are  tubes  from  the 
cortex.  (This  is  a  typical  case  of  •  B  right's  Disease  '  in 
its  most  exact  sense.) 

Not  uncommonly  chronic  bronchitis  is  the  prominent 
complaint.  It  is  not  at  all  uncommon  to  find  an-  elderly 
person  undergoing  the  vaso-renal  change  with  a  large 
heart,  to  have  an  attack  of  bronchitis  which  lingers  in 
a  chronic  form  ;  while  mitral  insufficiency  develops  with, 
of  course,  venous  congestion  behind  it  ;  in  which  the 
vessels  of  the  bronchias  share.  There  is,  too,  congestion 
of  the  pulmonic  circulation.  Before  long  some  vesicular 
emphysema  is  added.  A  well-marked  case  of  this  kind 
came  under  my  notice  a  little  time  ago  at  Bournemouth, 
whither  the  patient  had  wisely  retired. 

The  accompanying  plate  '  was  made  from  strongly- 
marked  typical  cases  of  emplvysema,  chronic  bronchitis, 
and  succeeding  dropsy,  by  the  late  Dr.  Basham.  It  gives 
a  vivid  conception  of  the  state  of  the  tissues  where  the 
closing  scenes  of  the  vaso-renal  change  are  associated 
with  bronchitis,  and  is  highly  instructive.' 

Sir  J.  G.,  aged  56,  came  under  my  care  with  the 
following  complications.  He  had  oedema  in  both  legs,  a 
large  heart  beginning  to  yield  ;  he  had  old-standing  renal 
mischief,  and  a  recent  effusion  into  the  right  pleura. 
After  a  time  a  large  infarct  was  developed  in  the  left  lung; 
and  the  respiration  became  so  embarrassed  that  his 
medical  attendant  and  myself  saw  no  hope  for  him  except 
by  drawing  off  the  fluid  from  the  right  chest,  in  order  to 
give  him  breathing-space.  Two  pints  and  a  half  of  fluid 
were  drawn  off  with  an  aspirator,  the  lung  coming  down 


Emphysema  &  Chrome  Bronchitis 


X 

V-^:  or 

big-.!.  -■_  -■     ■• 

RiLmoruiry  tissue  from,   emphysematous  lung. 


%2. 


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.Q'sJ^ssS^"''     BronrliLaL  rrvurcus'  m&rrvbr 


Fw:  4. 


i.:-%$[,/'  ? ■.#;•;'  /*;-/ 


Sputa    Chronic  Broruiutis  witfi,  Dropsy. 


•'■%:■)  '*:Hj  -; 


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Fatty     conditi/jTU    of   small     art&ry 
axLjcirilnq    emphysematous    poachy. 

WP.  Baskam.   del. 


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Front    right  auricle.-. 


From,   rigid:*    vexibrucLe/ . 

Heart    Filtrr. 


T/Way.lith.. 


.  ADVANCED  STAGE.  169 

in  the  most  satisfactory  manner ;  which  relieved  his 
breathing  greatly,  and  enabled  him  to  rally.  Three 
weeks  later  death  took  place  suddenly.  There  was  no 
post-mortem. 

Surg. -Gen.  J.  P.,  aged  72,  was  subject  to  attacks  of 
angina  pectoris  vaso-motoria.  He  had  the  large  heart 
and  hard  arteries  of  the  vaso-renal  change,  with  early 
commencing  mischief  in  the  aortic  valves  (insufficiency). 
The  case  progressed  at  a  marked  rate  during  the  eighteen 
months  he  was  under  observation ;  death  occurring  from  a 
severe  fit  of  angina. 

E.  C,  aged  60,  had  long  manifested  the  indications  of 
the  vaso-renal  change  complicated  with  an  impetiginous 
eczema,  for  which  she  was  under  the  care  of  the  late  Sir 
Erasmus  Wilson.  Despite  all  he  could  do,  she  sank 
exhausted  from  the  pain  and  itching  of  the  skin  affection ; 
which  extended  over  the  whole  of  the  body,  except  the 
face  and  hands. 

These  cases  illustrate  the  various  aspects  assumed  by  the 
vaso-renal  change  when  an  advanced  stage  is  reached. 
They  might  be  multiplied  indefinitely;  but  are  sufficient  to 
demonstrate  the  necessity  for  recognising  the  general  con- 
dition underlying  the  prominent  malady.  The  term, 
?  Bright's  Disease '  could  hardly  be  applied  to  all  these 
cases ;  in  many  of  which  the  renal  complications  were 
latent,  and  the  kidneys  attracted  no  attention  from  begin- 
ning to  end. 

Venous  Fulness. — The  consequences  of  the  failure  of  the 
heart's  energy  are  felt  in  the  venous  system,  and  are 
called  by  the  Germans  Riickwirkung.  Of  course  such 
are  markedly  developed  where  there  is  mitral  disease,  or 
any  lung   complication  causing  obstruction   to    the   pul- 


i/o  VASO-RENAL  CHANGE. 

monic  circulation.  (In  such  cases  the  pulmonary  artery 
becomes  the  seat  of  the  atheromatous  change.)  There 
may,  or  may  not  be  any  regurgitation  at  the  tricuspid 
orifice ;  but  such  is  commonly  the  case.  Pulsation  may 
be  visible  in  the  jugular  veins ;  while  the  systole  of  the 
right  ventricle  is  felt  distinctly  in  the  liver-pulsation,  which 
is  often  very  marked.  Commonly  the  liver  is  enlarged ; 
indeed,  if  it  be  not  greatly  enlarged,  it  is  significant  of 
cirrhosis,  which  prevents  its  swelling.  The  valveless 
portal  circulation  feels  the  venous  congestion  markedly. 
The  spleen  is  enlarged.  There  is  gastric  catarrh  giving  a 
feeling  of  fulness ;  even  when  the  viscus  is  empty.  There 
is  congestion  of  the  vessels  of  the  mucous  lining  of  the 
bowels,  with  great  evolution  of  gas ;  often  termed  ■  heart- 
wind.'  Sometimes  the  gas  comes  up  from  the  stomach 
with  roaring  explosions.  At  other  times  gas  is  developed 
in  the  colon ;  and  when  the  patient  is  already  scant  of 
breath  from  chronic  bronchitis  and  emphysema,  this  causes 
great  distress  by  preventing  the  descent  of  the  diaphragm. 
Very  frequently  some  wind  gets  pouched  in  the  corner 
where  the  transverse  passes  into  the  descending  colon ; 
and  much  colicky  pain  is  the  result.  This  is  often  com- 
plained of  by  the  patient  as  'pain  in  the  heart,'  and  is  the 
more  confidently  referred  to  the  heart  if  the  wind  compress 
the  heart  (through  the  thin  diaphragm)  with  its  elastic 
pressure,  and  cause  the  heart's  action  to  be  irregular. 
This  may  occur  even  if  there  be  no  valvular  mis- 
chief present  in  the  heart.  Sometimes  there  is  diar- 
rhoea. Then  there  is  often  congestion  of  the  hemor- 
rhoidal vessels,  giving  rise  to  piles,  or  rectal  trouble,  and 
much  itching  at  the  anus.  Under  such  circumstances  the 
prostate    frequently  enlarges.     No    uterine    haemorrhage, 


ADVANCED  STAGE. 


i?i 


so  far,  has  ever  come  under  my  notice  as  a  sequel  of 
heart-failure.  Catarrh  of  the  bladder,  however,  is  found. 
Fresh  cloudy  swelling  occurs  in  the  portions  of  the 
kidneys  remaining  sound,  with  growth  of  new  connective 
tissue  ;   the   old  mischief  and  the  new  often  being  con- 


Fig.  19.— Section  of  the  Cortex  of  the  Kidney,  from  a  case  of  vaso- 
renal change,  in  a  man  56  years  of  age,  with  a  syphilitic  history. 
This  shows  an  acute  congestion  occurring  in  interstitial  nephritis- 
All  the  vessels  are  injected  with  blood,  notably  the  vascular  tuft  of 
the  glomerulus,  a.  Neither  the  glomerulus  b  nor  c  show  any  vessels  ; 
probably  because  their  function  has  been  destroyed  by  the  fibroid 
change  which  has  occurred,  leading  to  their  contraction  and 
degeneration,  d  is  a  small  artery  with  thickened  walls  ;  particularly 
the  intima  is  so  increased,  as  almost  to  occlude  the  vessel.  The 
epithelium  of  the  tubules  is  undergoing  parenchymatous  degenera- 
tion.    Magnification,  200  diameters. 

spicuous  by  the  contrast.  Venous  congestion  is  a  certain 
provocative  of  albuminuria;  and,  sooner  or  later,  albumen 
is  present  in  the  urine.  At  first  it  appears  fitfully,  but  in 
time  its  presence  is  constant.  At  this  point  nothing  could 
add  to  the  gravity  of  the  case ;   but  the  appearance  of 


172  VA SO-RENAL  CHANGE. 

albumen  is  of  sinister  omen.  There  are  times  when  some 
difficulty  is  experienced  in  estimating  the  gravity  of  albu- 
minuria ;  but  there  is  none  here.  Indeed  it  speaks  only 
too  plainly ;  and  its  accents  are  those  of  waning  hope. 
Sometimes  the  patient  makes  a  rally ;  but  it  is  only 
of  a  temporary  character, — to  be  succeeded  by  a  graver 
condition. 

The  preceding  illustration  shows  recent  renal  mischief 
occurring  in  kidneys  the  seat  of  old-standing  disease.  It 
shows  the  microscopic  appearance  of  kidneys  in  the  con- 
dition of  those  of  which  Dr.  Bright  has  shown  us  the 
gross  changes. 

There  is  recent  congestion  amidst  the  old  interstitial 
change.  Such  is  the  condition  of  the  kidneys  when  new 
mischief  is  afoot  in  them  ;  whether  this  be  set  up  as  a 
direct  consequence  of  the  venous  congestion  of  a  failing 
heart ;  or  be  recent  nephritis  started  by  a  debauch,  or 
exposure  to  cold,  as  occurred  in  Dr.  Bright's  cases. 
When  such  is  the  case  the  kidneys  are  swollen ;  and  so 
larger  than  the  small  red  granular  kidney  found  when  the 
vaso-renal  change  comes  to  an  end  without  fresh  kidney 
complications. 

Dropsy,  too,  puts  in  its  appearance.  At  first,  perhaps 
the  patient  only  notices  some  pufhness  about  the  ankles 
at  bedtime,  all  traces  disappearing  in  the  night ;  but  the 
next  evening  the  puffiness  is  again  visible.  An  attack  of 
bronchitis,  or  pneumonia  may  develop  dropsy  rapidly. 
A  brisk  purge,  with  diuretics,  may  give  considerable 
relief;  sometimes  diarrhoea  comes  on  of  itself.  In  some 
persons,  as  in  the  case  of  R.  B.  (p.  165),  the  dropsy,  after 
attaining  very  considerable  proportions,  passes  away  for  a 
comparatively  long  time.     This  was  also  very  conspicuous 


ADVANCED  STAGE.  173 

in  a  typical  case  of  large  white  kidney  at  the  Victoria 
Park  Hospital.  After  the  legs  had  been  much  swollen, 
but  compatible  with  the  patient's  being  able  to  walk,  the 
case  slowly  yielded  to  treatment;  and  the  woman  was 
under  care,  off  and  on,  for  three  years.  She  ultimately 
sank  from  uterine  haemorrhage  at  the  change  of  life. 
More  commonly  the  rally  is  of  brief  duration,  the  dropsy 
returning  as  the  heart  fails  more  and  more ;  the  urine 
becoming  scantier  and  denser,  and  more '  highly  charged 
with  lithates.  Effusion  takes  place  into  the  serous  sacs, 
which  aggravates  the  distress ;  while  effusion  within  the 
cranium  is  a  not  uncommon  cause  of  death.  Or  oedema 
glottidis  closes  the  scene. 

Death. —Sudden  death  is  found  not  uncommonly  in  the 
laterr  or  even  the  final  stages  of  the  vaso-renal  change. 
Sometimes  it  occurs  in  the  midst  of  apparent  health ;  and 
sudden  death  without  enlargement  (to  any  extent)  of  the 
decayed  heart  is  one  mode  of  ending  in  these  cases.  But 
far  more  commonly  the  case  progresses  with  the  measured 
march  of  a  Gregorian  chant  to  the  bitter  end  ;  dropsy, 
effusion  into  the  serous  sacs,  embarrassed  breathing,  and 
sodden  limbs  adding  to  the  sufferer's  discomfort,  till  life 
is  indeed  a  burden.  At  last  the  patient  dies ;  worn  out 
with  sheer  exhaustion  and  carbonic  acid  poisoning. 

Death  presents  itself  in  many  terrible  forms;  but  to  see 
a  person  of  good  family  history,  and  naturally  good  con- 
stitution, wear  out  with  the  phenomena  of  a  failing  heart, 
is  one  of  the  most  painful  of  all  sights  which  even  the 
sick-room  can  afford. 

Such,  then,  is  the  end  of  a  change  which  often  is  visibly 
afoot  twenty,  thirty,  or  even  forty  years  before  its  career 
is   finally   run.       It  presents    us  with  many  and  varied 


174  VASO-RENAL  CHANGE. 

phenomena,  as  we  have  seen.  Probably  all  its  manifesta- 
tions are  not  yet  within  ken  ;  and  as  time  goes  on  and 
experience  accumulates,  other  maladies  may  be  found  to 
be  linked  with  it  causally.  The  first  departure  physio- 
logically is  the  reversion  of  the  liver  to  the  uric  acid 
formation  ;  and  the  presence  of  uric  acid  in  excess  in  the 
blood  provokes  a  growth  of  the  lowly  connective  tissue — 
the  wander-cells  of  the  mesoblast — at  the  expense  of  the 
higher  tissues,  in  the  blood  vessels  and  in  the  kidneys.  The 
only  other  tissues  directly  affected  are  the  two  muscular 
ends  of  the  circulation — the  heart  at  the  centre,  and  the 
arterioles  at  the  periphery.  But  in  time  these  become 
affected  by  the  growth  of  connective  tissue,  which  accu- 
mulates in  the  coronary  arteries  till  the  nutrition  of  the 
large  heart  fails  ;  so  that  we  see  that  in  the  end  the  con- 
nective tissue  works  the  ruin  of  its  muscular  confederate. 

But  betwixt  the  first  reversion  to  the  uric  acid  forma- 
tion and  the  failing  hypertrophy — the  beginning  of  the 
end — lies  an  immense  area,  covered  by  many  maladies 
and  much  morbid  action.  Many  of  these  have  been 
hitherto  regarded  as  independent  maladies  ;  but  they  can 
be  seen  to  be  really  but  parts  and  fragments  of  this  vast 
vaso-renal  change  ;  and  which  in  future  will  be  described 
as  such.  Without  some  acquaintance  with  the  whole 
morbid  process  it  is  impossible  to  rightly  comprehend 
these  various  parts  and  fragments. 

At  least,  they  have  become  clearer  to  myself  since 
being  able  to  grasp  the  whole,  and  take  a  bird's-eye  view 
of  it;  both  as  to  their  nature,  their  diagnosis  and  prog- 
nosis, and,  further,  their  treatment.  By  tracing  the 
pathological  chain  backwards,  link  by  link,  first  one 
morbid  action  and  then  another  come  into  view. 


ADVANCED  STAGE.  175 

Getting  back  to  the  first  beginnings,  one  is  now  able  to 
detect  the  vaso-renal  change  at  a  very  early  period  ;  and, 
consequently,  to  take  measures  to  stay  its  course — to  add 
to  length  of  days,  and  avoid  much  discomfort.  Feeling 
this  in  my  own  case,  and  realizing  how  my  hands,  as  a 
practitioner,  have  been  strengthened  by  this  knowledge, 
my  hope  is  that  it  may  be  equally  valuable  and  useful  to 
others. 


CHAPTER  VI. 


PRACTICAL    CONSIDERATIONS. 


a.  Insurance  Office  View  of  Life  ;  b.  Surgical  Aspect  of  Vaso-Renal 
Change;  c.  Relations  of  Stomach  and  Liver;  d.  Treatment  — 
Dietary. 

From  the  foregoing  considerations  it  is  abundantly  clear 
that  when  a  man  '  gets  the  gout,'  it  is  not  something 
added  to  the  healthy  normal  man ;  but  something  taken 
away  from  him.  Indeed  it  is  a  minus,  not  a  plus,  quantity. 
The  liver  fails  in  its  function  of  the  urea  formation ;  and, 
in  its  helplessness,  reverts  towards  the  uric  acid  formation 
of  an  earlier  and  lowlier  form  of  life.  It  is,  indeed,  a 
species  of  involution — a  turning  back,  or  retrogression.  In 
other  words,  it  is  the  undoing  of  evolution.  It  is  a  loss 
of  power,  a  falling  back.  The  liver  reverts  to  the  uric 
acid  formation  ;  and  the  presence  of  urates  in  the  blood- 
current  is  the  portent  of  innumerable  troubles,  and  ulti- 
mately grave  structural  changes.  Vast  and  varied  are  the 
pathological  outcomes  of  a  blood  surcharged  with  waste 
matters ;  which  are  themselves  the  outcome  of  albumen- 
metamorphosis.  Sublatd  causa  tollitur  effectus.  If  this  uric 
acid  formation  can  be  arrested,  put  in  abeyance,  or  to 
some  extent  rectified,  then  comfort  and  length  of  days 
are  possible.     Both  will  be  in  proportion  to  the  influence 


PRACTICAL  CONSIDERATIONS.  177 

that  can  be  brought  to  bear  upon  the  liver  in  its  func- 
tion of  the  metabolism  of  albuminoids,  and  in  albumen- 
metamorphosis. 

If  the  individual  of  acquired  uric  acid  formation,  or  of 
inherited  uric  acid  diathesis,  persists  in  the  meat-eating 
proclivities  of  his  Norse  ancestors,  'the  beef  and  ale  of 
Old  England,'  it  is  obvious  to  the  meanest  intellect,  that 
matters  must  go  on  from  bad  to  worse.  When  such  an 
individual  persuades  himself  first,  and  then  protests  that 
'it  makes  no  matter  what  he  eats  or  drinks,'  he  is  prac- 
tising further  indulgence — viz.,  a  fallacy  to  cover  his 
failings.     It  does  matter  ;  and  a  good  deal,  too  ! 

Of  course,  it  is  not  difficult  to  understand  that  a  sudden 
repentance  after  long-existing  excess  will  no  more  always 
work  a  cure  in  this  liver-backsliding,  than  will  repentance 
alter  the  character  of  a  hardened  sinner  in  all  cases.  If 
the  individual  goes  on  eating  and  drinking  just  what  the 
palate  pleases,  the  system  will  suffer.  More  and  more 
uric  acid  will  be  formed ;  and  further  and  more  extensive 
injury  will  be  done  to  the  organism — bad  going  to  worse. 
Attacks  of  acute  gout  may  clear  the  system,  as  so  many 
somatic  thunderstorms.  Secondary  inflammations  may 
achieve  the  same  end,  but  carry  with  them  a  distinct 
danger  to  life.  The  kidneys  must  become  further  muti- 
lated, or  destroyed.  The  arteries  will  wax  harder  and 
more  brittle,  and  so  are  more  liable  to  rupture.  Secondary 
valvular  mischief  is  fostered  in  the  enlarged  heart.  The 
spring  is  running  down,  as  Dr.  Goodhart  so  happily  puts  it. 

To  limit  the  albuminoid  elements  in  the  food  is  the 
first  step  to  be  taken.  They  should  be  brought  down  to 
the  point  of  the  actual  requirements  of  the  organism. 
The  individual  must  have  the  issue  placed  plainly  before 

12 


178  VASO-RENAL  CHANGE. 

him  ;  and  then  he  must  make  his  choice.  The  alternative 
is  not  a  pleasant  one.  Fourteen  years  of  personal  experi- 
ence have  taught  the  writer  that  it  is  nearly  as  irksome  to 
avoid  the  gout  as  it  is  painful  to  have  it.  But  the  alter- 
native is  decidedly  the  safer  practice.  The  inherited  satis- 
faction at  the  sight  of  a  huge  joint  of  meat  dies  away  as 
the  conviction  strengthens  that  it  is  not  good  food  for 
one.  Where  common-sense  rules,  the  appetites  obey — in 
some  other  matters  as  well  as  the  pleasures  of  the  table. 
Self-control  and  the  subordination  of  the  appetites,  like 
self-restraint  in  the  matter  of  the  passions,  carries  with  it 
its  own  reward.  '  Verily,  of  all  carnal  pleasures  cometh 
satiety  at  the  last,'  said  Kingsley's  monk,  when  asked  to 
sit  after  a  prolonged  experience  of  sitting  on  the  seat  of  a 
boat.  Lust  leads  to  impotence.  Indulgence  at  table  ends 
in  hepatic  reversion.  Gout  in  its  Protean  forms  is  the 
Nemesis  of  the  meat-eater.  '  Justice  has  a  leaden  foot, 
but  an  iron  hand.'  So  may  gout.  Whatever  statement  the 
gouty  man  may  put  forward  to  excuse  himself,  the  fact 
remains ;  and  '  gout  is  the  disease  of  those  who  will  have 
it,'  said  Meade  ;  and  he  was  perfectly  right. 

A  short  story  will  put  the  matter  in  its  most  illustrative 
light.  One  day  the  writer  met  with  Dr.  Z.,  one  of  our 
most  learned  and  honoured  physicians.  Discussing  the 
matter  of  the  uric  acid  formation,  Dr.  Z.  said  : 

'  You  attach  great  importance  to  the  dietary,  Dr.  F.  ?' 

'  Most  assuredly,'  was  my  reply.  .  '  The  avoidance  of  all 
albuminoids,  especially  the  flesh  of  the  larger  animals,  is 
the  cardinal  matter.' 

His  comment  was  :  '  I  am  delighted  to  hear  it.  I  am 
physician  to  an  insurance  office,  and  recently  we  had  a 
proposal  from  a  gouty  man  who  sometimes  had  transient 


PRACTICAL  CONSIDERATIONS.  179 

and  intermittent  glycosuria.  Of  course,  our  first  im- 
pression was  to  reject  the  life  summarily.  However, 
it  was  decided  to  wait  till  the  medical  report  came  in. 
When  it  arrived,  it  was  found  to  be  signed  by  Dr.  X. 
Now,  I  know  Dr.  X.  very  well,  and  also  know  that  he 
would  not  let  a  patient  of  his  eat,  or  drink  too  much  ;  and 
on  this  consideration  the  life  was  ultimately  accepted.' 

The  story  is,  indeed,  not  without  its  moral.  It  was 
just  the  same  difference  as  with  a  man  with  a  hernia. 
Well  trussed,  the  life  is  a  fair  one ;  neglected,  no  office  in 
the  world  would  look  at  it.  Allowed  to  eat  and  drink 
what  he  liked,  and  as  much  as  he  chose,  the  proposer  was 
certain  of  rejection.  In  the  hands  of  a  judicious  medical 
man  possessed  of  much  force  of  character,  and  able  to 
influence  a  patient  beneficially,  the  proposal  was  accepted. 
Nor  can  I  regard  the  action  taken  as  anything  but  sound 
common-sense.  It  is  not  likely  that  the  proposer  was 
accepted  as  a  first-class  life ;  but  he  was  accepted.  And 
that  fact  speaks  for  itself. 

To  reduce  the  dietary,  as  regards  its  proteids,  to  the 
capacity  of  the  liver — in  other  words,  to  '  level  down  '  to 
the  liver — is  the  first  step  to  be  taken.  This  not  only 
relieves  the  uric  acid  formation,  but  it  gets  rid  of  its 
untoward  consequences.  What  did  Dr.  Murchison  say 
before  the  Royal  College  of  Physicians  of  London,  in 
1874  ? — ■'  The  day,  I  believe,  will  come  when,  with  a  more 
perfect  knowledge  than  we  now  possess  of  the  healthy 
functions,  and  of  the  signs  of  functional  derangement  of 
the  liver,  we  shall  be  enabled  to  prevent,  or  to  arrest  at 
their  commencement,  many  of  the  most  serious  maladies 
to  which  mankind  are  liable,  and  thereby  to  add  another 
chapter  to  the  volume  of  preventive  medicine.' 

12 — 2 


i8o  V  A  SO-RENAL  CHANGE. 

Further  intimacy  with  the  liver  and  its  derangements 
certainly  places  myself  in  the  camp  of  Dr.  Murchison  ;  if 
it  is  impossible  to  go  the  length  of  Dr.  Matthew  Baillie. 
If  persons  of  the  uric  acid  formation  could  only  realize 
the  importance  of  adapting  their  dietary  to  the  capacity 
of  their  livers,  they  would  know  how  much  they  could  add 
to  their  lives  from  an  insurance  point  of  view.  That  is 
one  practical  matter. 

The  Surgical  Aspect  of  the  Vaso-Renal  Change. — For 
some  time  past  surgeons  have  become  fully  alive  to  the 
importance  of  ascertaining  the  condition  of  the  kidneys 
before  operating  on  persons  of  middle  age,  or  advanced 
life.  Persons  who  have  doubtful  kidneys  are  best  left 
alone,  as  the  operation  is  pretty  certain  to  end  in  disaster. 
For  this  end  they  have  the  urine  carefully  tested  for 
albumen  and  sugar ;  and  more  recently  a  quantitative 
analysis  of  the  urea  is  made.  But  even  this  last  is  but  a 
mockery  if  one  solitary  examination  only  be  made.  The 
great  variation  of  the  urine  from  day  to  day  is  notorious 
in  such  persons.  One  examination  may  be  perfectly  mis- 
leading. The  output  of  urea  one  day  may  be  up  to 
normal,  or  above  it ;  but  how  about  next  day,  or  that  day 
week  ?  It  may  be  far  below  the  healthy  average ;  and, 
what  is  more,  may  be  far  nearer  the  usual  urine  of  the 
individual  than  that  first  examined. 

Only  while  writing  this  chapter  a  neurotic  lady  of  the 
uric  acid  formation  brought  some  urine  with  her,  as 
requested.  Its  specific  gravity  was  1025.  From  her 
account  of  herself,  and  the  clinical  facts  of  the  case, 
instead  of  this  being  a  fair  average  specimen  of  her  urine, 
it  was  a  most  unfair  sample.  It  represented  the  exception 
rather  than  the  rule.     It  was,  indeed,  a  dense,  concen- 


PRACTICAL  CONSIDERATIONS.  181 

trated  urine,  following  upon  the  heels  of  a  large  output  of 
watery  urine.  Suppose  the  lady  was  a  patient  about  to 
be  operated  upon,  the  urine,  instead  of  speaking  the  truth, 
was  lying  as  hard  as  an  Oriental  false-witness ;  and, 
instead  of  a  guide,  was  utterly  misleading. 

The  following  case  illustrates  what  is  said  above,  and  is 
distinctly  instructive.  In  1876  Mr.  W.  F.  Teevan  asked 
me  to  examine  for  him  a  man  in  St.  Peter's  Hospital 
who  had  come  from  South  Africa  to  be  operated  upon  for 
stone  in  the  bladder.  A  tumour  in  the  abdomen  was  the 
immediate  cause  of  my  being  requested  to  see  the  case. 
-  I  passed  over  the  tumour  as  unimportant,  but  strongly 
advised  no  operation ;  stating  it  to  be  my  opinion  that  the 
patient  had  chronic  heart  and  kidney  changes.  This 
opinion  was  represented  to  the  patient  and  his  friends, 
but  the  patient  begged  to  be  operated  upon.  He  was  cut, 
and  died.  His  kidneys  were  shrunken  and  contracted,  till 
scarcely  a  sound  piece  could  be  found ;  one  weighed  one 
ounce  and  three  quarters,  the  other  three  and  a  quarter. 
The  heart  weighed  fifteen  ounces,  and  was  fatty.  Such  is 
the  report  of  the  post-mortem  examination,  which  I  did 
not  see.  The  letter  which  the  patient  brought  with  him 
from  the  Cape,  stated  that  repeated  examination  of  the 
urine,  chemically  and  by  the  microscope,  gave  no  trace 
of  albumen  or  casts ;  and  on  this  negative  evidence  the 
kidneys  were  assumed  to  be  sound.  As  the  event  proved, 
this  opinion  was  utterly  erroneous.'  Such  a  case  tells  its 
own  story,  and  carries  with  it  its  own  moral.  There  was 
no  carelessness  whatever  on  anyone's  part ;  the  urine  had 
been  examined  repeatedly,  both  chemically  and  with 
microscope.  The  medical  attendant  had  conscientiously 
discharged    his  duty — up  to  his   lights.      Yet  the  result 


1 32  VASO-RENAL  CHANGE. 

demonstrated,  beyond  any  question  or  cavil,  that  the  man 
was  in  the  advanced  stage  of  vaso-renal  change  ;  and 
fully  vindicated  my  opinion  that  an  operation  should  not 
be  attempted.  No  doubt  the  letter  from  his  medical 
attendant  outweighed  my  opinion  ;  and  under  identical 
circumstances  would,  with  most  surgeons ;  yet  all  the 
same  the  case  furnishes  a  typical  example  of  dispro- 
portionate trust  in  the  renal  secretion  as  an  evidence  of 
vaso-renal  change. 

In  future,  surgeons  should  have  their  patients  thoroughly 
examined  before  deciding  the  question  of  operation : 
examined  as  a  whole,  and  not  in  part.  The  urine 
characteristics  are  well  enough ;  but  they  should  be 
weighed  in  the  balance  in  connection  with  the  rest  of  the 
evidence.  In  a  law  court,  in  a  complicated  case  all  the 
witnesses  are  examined,  and  most  of  them  cross-examined, 
before  a  decision  is  arrived  at.  The  decision  is  not 
allowed  to  rest  upon  the  statement  of  one  solitary  witness 
of  doubtful  character.  And  since  the  day  of  the  late 
Dr.  Mahomed  the  urine  is  no  more  than  a  doubtful 
character  — as  regards  vaso-renal  change.  The  condition 
of  the  vascular  system  taken  as  a  whole  is  more  worthy  of 
trust  than  the  urine.  But  no  one  portion  of  the  wide- 
spread change  should  be  taken  exclusively  ;  all,  and  every- 
thing should  be  weighed  before  a  decision  for,  or  against 
the  vaso-renal  change  is  made.  Mr.  Teevan's  old  gentle- 
man put  his  faith  in  the  result  of  the  examination  of  the 
urine ;  and  his  life  paid  forfeit  for  his  misplaced  trust 
(probably  the  suffering  he  endured  was  not  without  effect 
upon  his  decision) ;  and  likely  enough  many  another  old 
man  has  lost  his  life  from  the  false-witness  borne  by  his 
renal  secretion.     When  the  Resident  Medical  Officer  of 


PRACTICAL  CONSIDERATIONS.  183 

the  Leeds  Public  Dispensary,  going  round  his  wards  with 
Mr.  Pridgin  Teale,  we  came  to  an  old  man  whom  he  had 
cut  for  stone,  whose  appearance  aroused  my  suspicions. 
An  explanation  was  tendered  to  me  that  his  water  had 
been  examined  and  found  all  right.  On  asking  the  man  to 
put  out  his  tongue,  it  revealed  the  brown  hue  of  uraemia. 
The  request  was  made  that  the  kidneys  should  be  ex- 
amined at  the  autopsy.  Both  were  found  hard,  granular, 
contracted  and  containing  cysts. 

When  a  surgeon  suspects  that  a  patient  upon  whom  he 
is  asked  to  operate  (or  desirous  to  operate)  is  the  subject 
of  vaso-renal  change,  or  has  diseased  kidneys,  he  will  do 
well  to  take  some  other  matters  into  consideration  than  a 
mere  specimen  of  the  urine  passed.  That  is  another 
practical  matter. 

The  Relations  of  the  Stomach  and  Liver. — The  mutual 
relations  of  the  liver  and  stomach  are  of  deep  practical 
interest.  Under  certain  circumstances  the  stomach  is  the 
protector  of  the  liver  ;  but  at  other  times  it  is  a  fell  tyrant. 
It  may  be  well  to  dispose  of  the  latter  matter  at  once. 
Albuminoids  are  largely  digested  in  the  stomach  ;  and  the 
flesh  of  animals  is  often  grateful  to  a  stomach  which 
resents  vegetables  and  uncooked  starch.  Consequently, 
in  order  to  avoid  discomfort,  a  dietary  consisting  largely 
of  flesh  is  adopted  by  many  persons — much  to  the  disturb- 
ance of  the  liver.  Who  does  not  know  the  sallow  spare 
woman  of  the  bilious  diathesis,  whose  features  tell  of  the 
sick  headaches  which  she  has  endured  ;  who  lives  upon  a 
little  lean  meat,  and  a  piece  of  dry  bread  with  a  little 
weak  tea  without  milk  or  sugar :  and  declares  that  her 
stomach  will  only  tolerate  such  food  ?  She  is  bilious ; 
and  on  such  dietary  she  is  likely  to  remain  bilious.     The 


1 84  V A  SO-RENAL  CHANGE. 

stomach  may  be  satisfied  with  such  a  dietary  ;  but  the 
liver  is  certainly  embarrassed  by  it.  There  is  a  great 
deal  too  much  albuminoid  matter  in  the  food  for  its 
comfort.  It  first  of  all  provides  biliousness  with  sick 
headaches,  and  a  loathing  of  all  food ;  which  gives  it 
a  respite  for  the  time  at  least.  Later  on  in  life  the 
reversion  to  the  uric  acid  formation  is  established.  A 
number  of  cases  have  come  under  my  notice  where  the 
craving  of  the  stomach  has  led  to  embarrassment  of  the 
liver;  and  the  person  has  become  gouty  through  being  a 
dyspeptic.  One  typical  case  of  a  bilious  woman  who 
lived  on  dry  bread,  a  little  lean  meat  and  simple  tea,  rises 
up  in  my  mind.  She  had  been  a  sufferer  for  years  ;  her 
face  was  indicative  of  often  being  bowed  down  with  pain. 
After  much  exhortation  she  was  induced  to  take  to  bread 
and  butter,  and  milk  puddings  without  eggs  in  them,  and 
improved  markedly ;  and  ten  years  later  was  in  much 
better  health. 

But  far  more  frequently  the  stomach  is  the  protector  of 
the  liver.  A  congenitally  feeble,  or  what  Dr.  Budd 
denominated  an  '  insufficient  liver '  (a  term  endorsed  by 
Dr.  Murchison),  is  protected  by  a  poor  appetite,  and 
a  stomach  easily  offended.  The  one  cuts  down  the 
amount  of  food  taken;  the  other  puts  in  its  protest  against 
any  great  bulk  of  food.  Pain  and  suffering  are  the  conse- 
quences of  any  indulgence  at  table.  The  simplest  food 
only  can  be  taken,  and  that  too  in  very  moderate  quantities ; 
or  a  penalty  be  exacted  for  any  indiscretion.  Any  attempt 
to  take  a  good  meal,  and  then  a  long  interval  till  the  next 
meal,  is  fraught  with  discomfort.  This  is  well  seen  in  the 
case  of  the  neurotic  wife  of  a  Norse  husband.  Oblivious 
of  their  physical  differences,  she  will  assimilate  her  meals 


PRACTICAL  CONSIDERATIONS.  185 

to  her  liege  lord's  ways  and  customs.  He  has  a  good 
breakfast,  a  substantial  luncheon,  and  in  the  evening  an 
ample  dinner.  All  very  well  for  him,  who  has  large 
viscera,  and  can  take  in  large  quantities  of  food  at  once, 
and  then  fast  for  hours — waiting  for  a  good  appetite  to 
give  zest  to  his  enjoyment  of  the  coming  meal.  But  how 
about  his  wife  with  her  small  viscera  ?  If  she  fast  the 
same  time,  instead  of  a  good  appetite  she  has  a  headache, 
and  is  '  past '  all  food.  He  is  like  an  express  locomotive 
with  a  huge  tender  constructed  to  hold  large  quantities  of 
fuel,  so  as  to  run  long  distances  without  stopping.  She 
is  like  a  yard-engine  whose  tender  is  little  bigger  than  a 
coal-scuttle.  If  this  engine  set  off  for  a  long  run,  its 
tender  would  be  empty  before  it  got  half-way.  He  enjoys 
a  fast.  It  makes  her  ill.  She  must  have  small  quantities 
of  food  at  once,  and  at  brief  intervals.  She  can  do  very 
well  with  a  little  of  something  at  eleven  o'clock — an  inter- 
lude betwixt  breakfast  and  lunch.  Some  tea  and  bread 
and  butter  in  the  afternoon  are  acceptable.  Kettledrum 
is  a  modern  institution  ;  and  supplies  a  need  with  the 
modern  neurotic  of  small  digestive  organs.  Then  such  a 
lady  can  do  very  well  with  a  little  of  something  at  bed- 
time ;  and  in  cold  weather  is  all  the  better  for  some  beef- 
tea  and  baked  starch,  or  some  milk  and  malted  food  in 
the  small  hours  of  the  morning  in  cold  weather.  All  put 
together  it  does  not  amount  to  much.  But  on  such  a 
dietary  she  is  well  and  strong,  i.e.,  as  well  and  strong  as 
she  can  be. 

The  confirmed  dyspeptic  in  my  experience  is  usually  a 
neurotic  of  the  uric  acid  formation.  He  growls  at  his 
stomach  and  complains  of  his  dyspepsia,  knowing  what 
he  feels;  but  still  perfectly  misunderstanding  the  real  facts 


i86  VASO-RENAL  CHANGE. 

of  the  case.  Such  an  one  was  Tom  Carlyle — a  typical 
example  of  the  intellectual  dyspeptic.  Like  all  of  this 
class  he  was  irritable,  and  had  a  bad  temper.  '  That  hag 
dyspepsia  has  got  me  bitted  and  bridled,  and  turned  my 
living  day  into  a  waking  nightmare,'  he  complained.  As 
a  matter  of  fact,  dyspepsia  could  not  '  bridle  '  him.  It 
strove  hard,  but  had  little  success.  If  it  had  not  been 
for  dyspepsia  he  would  have  gone  to  his  grave  ere  middle 
age  was  reached.  It  was  just  this  dyspepsia  which  he 
cursed  so  savagely  that  enabled  him  to  make  old  bones. 
He  was  an  ingrate,  in  fact.*  Had  he  had  a  capable 
stomach,  what  would  his  liver  have  had  to  endure  ?  There 
is  a  deep-rooted  impression  abroad — almost  as  strong  as 
a  religious  conviction,  that  every  individual  ought  to  have 
four,  or,  at  very  least,  three,  good  meals  a  day.  That  so 
much  food  ought  to  be  eaten  by  everyone,  no  matter  who  ; 
and  many  dyspeptics  are  sufferers  for  their  devotion  to 
their  gastronomic  duties.  They  do  their  duty  to  the 
cook's  labours,  and  make  themselves  ill.  A  nineteenth 
century  liver  is  '  the  heir  of  all  the  ages  ' — the  heir  of  the 
good  and  bad  together.  The  Norseman's  appetite  is 
becoming  a  thing  of  the  past.  Their  modern  repre- 
sentatives cannot  gorge  themselves  on  pork,  and  swill 
beakers  of  ale  with  impunity,  as  did  the  Anglo-Saxon 
rovers,  and  the  Norse  vikings.  Athelings,  jarls,  Norman 
barons,  all  fed,  feasted  and  drank.  Every  man  who  could 
afford  it  kept  a  cook.  Charles  V.  of  Germany  was  a  gross 
feeder,  and  retired  from  public  life  sodden  with  gout.  He 
got  his  reward  ;  and  the  picture  of  him  drawn  by  Lothrop 
Motley  is  that   of  an  ideal  gouty  man,  who  had  at  least 

*  He  said  of  himself:  'I   am  a  very  unthankful,  ill-conditioned, 
bilious,  wayward  son  of  Adam,  I  do  suspect.' 


PRACTICAL  CONSIDERATIONS.  187 

'  the  sweet  consciousness  of  guilt.'  This  is  what  Roger 
Ascham  saw  and  said  of  him  as  Charles  sat  at  the  dinner 
of  the  Knights  of  the  Golden  Fleece,  '  making  his  way 
steadily  through  sod  beef,  roast  mutton,  and  baked  hare, 
after  which  he  fed  well  on  a  capon.'  Nor  did  he  forgot 
to  drink  with  it  all.  '  He  had  his  head  in  the  glass  five 
times  as  long  as  any  of  them,  and  drank  no  less  at  once 
than  a  quart  of  Rhine  wine.'  He  deserved  the  gout :  and 
he  got  it. 

But  the  modern  descendants  of  the  old  Norseman  and 
the  mediaeval  nobles,  are  degenerating  as  regards  their 
eating  capacities  and  their  gastronomic  performances. 
The  blue  blood  carries  uric  acid  on  its  current.  The 
plebeian  alderman  who  does  not  know  who  his  grand- 
father was,  is  the  capable  feeder  of  to-day.  The  youth  of 
Punch,  who  was  down  in  the  shires  on  hunting  bent,  and 
ordered  up  the  round  of  boiled  beef  when  the  frost  would 
not  break  (after  an  ample  breakfast)  was  in  a  fair  way  to 
make  the  acquaintance  of  the  gout.  It  is  no  mere  acci- 
dent of  fashion  that  teetotalism  and  vegetarianism  are  in 
vogue  at  the  present  day  ;  or  that  the  brewer  prepares  a 
light  beer  rather  than  the  strong  ale  of  the  past.  Our 
railway-stations  are  placarded  with  the  advertisements  of 
prepared  foods  of  all  kinds.  Why  is  all  this  ?  Because 
the  English  are  losing  their  once  famous  powers  of 
digestion.  The  child  of  to-day  too  often  comes  into  the 
world  with  a  feeble  digestive  apparatus,  and  is  reared 
with  difficulty.  Often  its  mother  cannot  suckle  it,  and  it- 
is  artificially  fed,  reared  by  hand  ;  and  its  rearing  taxes 
the  best  energies  of  all.  And  when,  in  its  turn,  it  be- 
comes a  parent,  its  children  will  be  still  more  difficult  to 
rear. 


1 88  V A  SO-RENAL  CHANGE. 

And  at  this  point  something  may  be  said  about  the 
neurotic  dyspeptic  of  the  uric  acid  formation  as  a  parent. 
Those  who  reside  in  the  country  not  unfrequently  are 
prolific,  having  large  families  in  some  cases ;  and  living  to 
a  good  old  age.  But  the  urban  neurotic,  which  means 
the  bulk  of  these  beings,  is  a  failure  as  a  parent.  In  my 
own  experience  she  is  frequently  sterile  ;  or  has  one  child, 
a  delicate  little  creature.  If  she  have  had  more,  they  have 
perished  in  infancy  or  childhood.  Mr.  Cantlie  has  paid 
great  attention  to  the  degeneracy  of  Londoners,  and  on 
my  inquiring  of  him  what  was  the  end  of  the  degenerate 
Cockney  race,  his  reply  was  to  the  effect  that  it  usually 
succumbed  to  the  maladies  of  childhood.  He  has  ob- 
served a  certain  malformation  of  the  lower  jaw  in  London 
children  of  Cockney  parentage ;  and  this  he  has  not  seen 
either  in  the  workhouses  which  he  inspected,  or  in  the 
dissecting-room  at  Charing  Cross  Hospital,  in  individuals 
over  twenty-five  ;  and  very  rarely  over  twenty,  years  of 
age.  Probably  the  reversion  to  the  Cymric  type,  which  is 
so  conspicuous  in  urban  populations,  is  a  degeneracy  from 
the  Norse  type.  And  this  degeneracy  is  evidently  fostered 
by  the  circumstances  of  town-life. 

The  female  neurotic  dyspeptic  is  liable  to  trouble  con- 
nected with  her  ovaries,  in  my  experience.  Commonly 
she  has  an  irritable  ovary,  which  is  probably  somewhat 
altered  in  structure  ;  so  that  the  full  development  of  ova  is 
thwarted.  Certainly  she  has  often  a  tender,  swollen 
ovary,  much  aggravated  at  her  monthly  periods ;  and  this 
must  stand  in  some  relation  to  her  sterility.  She  certainly 
is  a  contrast  in  every  way  to  the  large  woman — the  typical 
mother  of  children.  Small,  active,  energetic,  unwearying  ; 
motherhood   is   not  her  vocation.     Her  one  child,  when 


PRACTICAL  CONSIDERATIONS.  189 

she  has  one,  is  herself  accentuated  and  more  pronounced. 
She  is  an  affectionate  wife,  a  brilliant  companion  ;  but 
not  the  mother  of  sons. 

Talking  with  an  American  lady,  a  perfect  specimen  of 
this  type,  she  showed  me  her  one  little  girl — a  human 
gurnet  ;  almost  like  an  inverted  cone,  tapering  from  the 
head  downwards — and  asked  my  opinion  of  her;  and  what 
she  would  grow  up  into.  My  reply  was  to  the  effect  that 
she  would  grow  up  '  a  bundle  of  nerves,  with  shrunken 
viscera  ' — a  not  very  hopeful  opinion  ;  but  only  too  likely 
to  be  verified. 

Such  children  should  be  sent  away  from  the  centres  of 
civilization  far  into  the  country.  Town-life  is  too  stimu- 
lating for  them.  They  are  being  civilized  off  the  face  of 
the  earth.  They  are  precocious.  Puberty  comes  on  while 
still  immature.  They  perish  early  ;  old  age  comes  upon 
them  before  the  time  of  middle  life.  They  frequently  die 
of  consumption.  The  lively,  sprightly  sylph,  '  all  up  and 
down,'  as  her  mother  describes  her;  that  is  either  elate  in 
high  spirits,  or  depressed  with  headache  :  she  alternates 
rapidly.  But  the  sword  wears  out  the  scabbard :  the 
spirit  exhausts  its  tenement  of  clay.  Those  die  young 
whom  the  gods  love :  the  fairy  children,  beautiful,  preco- 
cious, charming,  do  not  tarry  long  with  us. 

A  still  more  degenerate  being  is  the  scrofulous  or 
strumous  child — the  victim  of  joint  disease,  in  whom  the 
uric  acid  formation  is  so  notorious.  There  is  coarse- 
featured  scrofula,  and  fine-featured  struma  ;  but  the  end 
is  the  same — viz.,  phthisis.  The  feeble  digestive  organs, 
the  irritable  stomach,  and  the  insufficient  liver  cannot 
feed  the  system  and  the  tissues.  The  loathing  of  fat 
interferes  with  the  building  up  of  healthy  tissues  ;    and 


190  VASO-RENAL  CHANGE. 

tuberculosis  is  the  result.  Lugol  (on  Scrofula)  has  noted 
the  effect  of  town-life  upon  the  physique,  reducing  it 
towards  scrofula  ;  which  Laycock  held  was  a  reversion  to 
a  'lowly  ethnic  form' — a  term  which  quite  meets  the 
facts. 

When  the  neurotic  child  is  fairly  well,  it  is  desirable  to 
let  her  have  her  own  way  about  her  food.  Any  attempt  to 
feed  her  up,  to  raise  her  above  what  she  is,  only  further 
embarrasses  her  liver.  Cod-liver  oil  is,  however,  almost  a 
necessary  article  of  diet  with  her ;  being  the  only  fat  she 
can  assimilate.  It  is  not  the  best  fat :  but  it  is  the  only 
fat  she  can  take.  Milk  puddings,  and  stewed  fruit  and 
cream,  and  milk  with  malted  preparations,  should  form 
the  staple  of  her  food.  Bread-and-butter  puddings  are 
excellent.  If  she  loathe  cod-liver  oil,  try  her  with  toffee — 
the  good  old  homely  compound  of  butter  and  sugar,  so 
acceptable  to  the  young.  Many  a  little  neurotic  child 
lives  to  bless  me  for  pointing  out  to  her  mother  the  high 
food-value  of  toffee,  and  its  utility  as  a  means  of  supplying 
fat  for  the  tissue-wants.  Derision  and  surprise,  of  course, 
are  the  first  results  of  the  suggestion  of  toffee ;  because  it 
has  been  looked  at  merely  as  a  sweet — and  not  from  its 
food-value  point  of  view.  At  first  it  seems  like  harnessing 
Pegasus  to  a  market-cart ;  but  in  reality  it  is  an  admirable 
combination  of  carbo-hydrates  with  hydro-carbons. 

Such  a  child  is  a  dainty,  fastidious  feeder  ;  a  very  bright 
child,  but  very  difficult  to  feed.  The  bread  and  milk,  or 
porridge  and  milk,  so  admirably  adapted  for  the  nursery 
fare,  she  loathes  too  often.  Something  tasty  she  can  eat. 
Or  the  liquid  fat  of  fried  bacon  she  can  digest ;  and  ought 
to  have.  The  time-honoured  rules  of  the  nursery,  well 
suited  to  the  children  of  the  past,  must  be  relaxed  some- 


PRACTICAL  CONSIDERATIONS.  191 

what  in  her  case.  Compared  to  other  children,  she  is 
a  harebell  in  an  onion-bed.  She  is  the  product  of  civiliza- 
tion ;  and  her  high-strung  nervous  system  is  linked  with 
defective  assimilative  organs.  Her  liver  is  lacking  in 
capacity  ;  and  exhibits  a  marked  tendency  to  revert  to  the 
uric  acid  formation.  To  attempt  to  feed  her  up — under  the 
impression  that  by  so  doing  she  will  become  robust,  is  a 
profound  mistake.  She  cannot  be  fed  up  !  An  albuminoid 
dietary  will  not  swell  her  muscles,  and  fill  out  her  frame. 
It  will  only  cause  her  liver  to  form  more  uric  acid. 

Poor  man's  gout  is  her  ordained  lot,  i.e.,  in  some  form 
or  another.  She  often  has  palpitation,  and  has  a  com- 
paratively large  heart.  The  hypertrophied  heart  of 
anaemia  is  found  in  this  class  of  girl.  Only  the  other 
day  a  little  mite  appeared  at  the  hospital,  not  yet 
thirteen,  who  has  migraine  with  indigestion,  acidity, 
flatulence,  vesical  irritability,  and  sediments  in  her  urine ; 
and  on  examination  she  certainly  had  a  heart  dispro- 
portionately large  for  her  slight  body.  Her  father  and 
mother  are  robust  healthy  people ;  and  the  only  cause 
why  all  their  children  are  delicate  seems  to  be  the 
influence  of  town-life,  and  the  fact  that  the  mother  bore 
the  children  rapidly. 

The  neurotic  man  has  been  given  as  delineated  by 
Clifford  Allbutt  at  p.  63,  and  it  is  a  man  of  this  type — a 
neurotic  of  the  uric  acid  formation — whom  Dr.  Lauder 
Brunton  had  in  his  eye  when  he  wrote  :  '  Feeling  dull, 
weak,  and  melancholy,  the  sufferer  now  thinks  he  ought  to 
take  meat  three  times  a  day,  and  perhaps  during  the 
interval  of  his  meals  to  take  strong  beef-tea,  or  perhaps  a 
glass  of  milk  and  a  nip  of  brandy.  Yet  in  spite  of  all  this 
he  becomes  weaker  and  more  stupid,  and  more  melan- 


192  V A  SO-RENAL  CHANGE. 

choly  ;  and  no  wonder.  He  is  simply  further  overtaxing 
his  already  overworked  digestive  organs.  He  is  piling  up 
fuel  instead  of  removing  ash,  and  choking  the  vital  pro- 
cesses both  in  his  digestive  and  nervous  system.  What 
he  wants  is  not  more  nutriment,  but  a  more  rapid  removal 
of  waste ;  and  the  change  upon  the  adoption  of  a  proper 
system  of  treatment  is,  in  many  cases,  most  marked  and 
satisfactory,  both  to  the  physician  and  the  patient.'  In 
the  poor  man's  gout  and  the  rich  man's  gout  alike,  the 
albuminoid  elements  of  the  food  must  be  brought  down 
to  the  capacity  of  the  liver  to  deal  with  them.  This 
is  another  practical  matter. 

Relations  of  Uric  Acid  to  Acute  Disease. — What  relation 
the  existence  of  uric  acid  in  excess  in  the  blood  has  to 
sundry  acute  diseases,  is  a  matter  upon  which  it  is  only 
possible  to  speculate.  But  some  other  matters  than 
acute  articular  gout  are  coming  within  our  vision.  We 
have  seen  in  this  inquiry  that  indigestion,  flatulence 
and  acidity  are  as  certainly  due  to  uric  acid  in  persons  of 
the  neurotic  temperament ;  as  is  articular  gout  in  persons 
of  the  arthritic  temperament.  New  light  is  breaking  in 
upon  us.  In  all  colds  and  catarrhs  the  practical  man  of 
a  past  generation  commenced  with  a  mercurial  (usually 
combined  with  an  antimonial)  at  bedtime,  and  some 
purgative  medicine  next  morning  ;  and  then  pursued  the 
regular  treatment.  They  called  it  '  clearing  the  system.' 
We  are  certainly  all  familiar  with  the  pink,  or  red  lithates 
of  a  common  cold. 

Then,  again,  there  is  another  malady,  which,  like  a 
common  cold,  is  attributed  to  exposure  ;  and  which  is 
marked  by  a  large  output  of  urates ;  and  that  is,  acute 
rheumatism.     The  late  Dr.  Fuller,  who  was  an  authority 


PRACTICAL  CONSIDERATIONS.  193 

on  the  subject,  in  the  introduction  to  his  well-known  work, 
'  Rheumatism  and  Rheumatic  Gout,'  stoutly  maintains 
that  the  starting-point  is  a  matcrics  morbi  in  the  blood. 
'  And  if  the  blood  be  altered  in  character  it  is  practically 
the  same,  whether  it  contains  matter  foreign  to  the 
system,  and  altogether  morbid  in  kind,  or  whether  it 
contain  an  excess  only  of  some  material,  a  certain  amount 
of  which  is  compatible  with  health.'  Further  on  he 
writes  :  '  The  earliest  and  the  most  frequent  victims  of 
the  disease,  even  when  considering  themselves  in  tolerable 
health,  are  apt  to  experience  symptoms  clearly  denoting 
functional  derangement.  Though  strong,  perhaps,  and 
equal  to  much  bodily  exertion,  they  are  peculiarly  sensi- 
tive to  atmospheric  vicissitudes,  are  prone  to  perspire, 
and  their  perspiration  has  a  sour  disagreeable  odour, 
whilst  the  urine,  though  usually  clear  when  passed,  not 
unfrequently  deposits,  on  cooling,  a  red  brickdust  sediment, 
a  sediment  of  the  lithates  and  lactates.  So  constantly  are 
these  symptoms  associated  with  a  tendency  to  rheumatism, 
that  they  have  been  recognised  as  indicative  of  a  "rheu- 
matic diathesis,"  or,  in  other  words,  of  a  case  of  constitu- 
tion peculiarly  prone  to  the  incursion  of  rheumatism.' 
My  own  experience  is  in  harmony  with  what  is  written 
here  ;  and  though  acute  rheumatism  is  not  acute  poly- 
arthritic  gout,  it  has  sundry  relations  with  the  uric  acid 
formation.  Later  on  Dr.  Fuller  remarks  very  significantly, 
'  Moreover,  rheumatism  is  so  common  among  persons 
suffering  from  renal  disease.'  Lactic  acid  is  held  to  be 
the  particular  poison  of  acute  rheumatism ;  but  its 
production  has  some  association  with  a  pre-existing  state 
of  the  blood — though  it  is  not  yet  possible  to  say  what 
that  association  is. 

13 


194  VASO-RENAL  CHANGE. 

Medicinal  Treatment  of  the  Uric  Acid  Formation. — This 
branches  out  into  two  lines — (i)  the  preventive  treatment ; 
and  (2)  the  curative  treatment.  First  come  uric  acid 
solvents.  Sir  Charles  Scudamore  used  potash  in  acute 
gout ;  but  with  no  further  idea  than  the  crude  one  that  it 
was  an  '  antacid.'  Dr.  Garrod  first  pointed  out  that  lithia 
and  potash  are  true  solvents  of  uric  acid.  Uric  acid  is 
highly  soluble  when  combined  with  lithia,  or  potash  ;  and 
if  a  specimen  of  urine  containing  lithates  have  some 
liquor  potassii  added  to  it,  the  sediments  disappear  and 
the  fluid  becomes  clear.  To  wash  the  uric  acid  out  of  the 
body  daily  by  some  potash  and  lithia,  taken  every  morning 
with  a  good  draught  of  water — which  is  really  treating 
the  tissues  to  an  alkaline  bath — is  an  excellent  practice  ; 
yielding  the  most  satisfactory  results,  especially  in  florid 
persons  of  the  Norse  type.  The  Arab  folk  do  not  get  on 
so  well  with  this  line  of  treatment,  which  is  too  depressant 
for  them.  Potash,  as  a  muscle-poison,  acts  too  potently 
upon  them  ;  and  lithia  is  the  uric  acid  solvent  best  suited 
to  them.  Some  cannot  stand  lithia  ;  and  for  these  the 
acid  phosphate  of  soda  is  indicated.  Whatever  the  out- 
come of  the  uric  acid  formation — whether  arthritic 
trouble,  indigestion,  migraine,  or  eczema — uric  acid 
solvents  rarely  come  amiss. 

Colchicum  is  a  notable  remedy  in  gout ;  and  certainly 
eases  pain  in  acute  articular  gout.  But  the  chronic  resort 
to  colchicum  to  keep  off  the  gout  is,  in  my  opinion,  a 
most  pernicious  practice  —  the  person  who  does  this 
becoming,  in  time,  sodden  with  uric  acid. 

Hepatic  stimulants  are  excellent.  Whether  it  can  be 
affirmed  that  these  agents  can  raise  the  liver  which  is 
backsliding  by  reverting  to  the  uric  acid  formation,  exer- 


PRACTICAL  CONSIDERATIONS.  195 

rising  a  direct  action,  is  somewhat  doubtful ;  but  it  must 
be  admitted  that  the  facts  point  in  that  direction.  The 
good  effects  of  blue-pill  and  a  seidlitz  powder  upon  a  gouty, 
or  a  liverish  state  are  well  known  by  those  who  have  ex- 
perienced them. 

Elsewhere  ('  The  Diseases  of  Sedentary  and  Advanced 
Life  ')  the  writer  has  written :  '  Next  morning,  after  a 
good  dinner,  the  gouty  man  is  anxious  about  his  property; 
his  tenants  are  falling  behind  with  their  rents  ;  his  wife's 
health  causes  him  the  greatest  uneasiness ;  while  his 
eldest  son's  conduct  is  driving  him  to  despair.  •  After  a 
blue-pill  at  night,  and  a  seidlitz  powder  next  morning,  the 
outlook  is  rosier.  He  has  one  of  the  finest  estates  in  the 
county,  with  first-class  tenants  upon  it ;  his  wife  is  hale, 
and  in  good  health  ;  while  his  eldest  son  is  a  young  man 
of  excellent  promise,  whose  crop  of  wild  oats  is  not  going 
to  be  at  all  a  lush  one.  And  the  altered  state  of  mind  is 
all  brought  about  by  getting  rid  of  the  excess  of  uric  acid 
which  so  profoundly  affected  the  mind,  acting  like  a 
mental  poison.' 

The  list  of  cases  which  Abernethy  records  where  mer- 
curials and  cholagogues  did  so  much  good,  point  to 
cholaemia  and  lithaemia  being  the  morbific  states.  A 
cholagogue  like  mercury  is,  however,  not  suited  for 
habitual  use.  Rather  should  it  be  resorted  to  occasion- 
ally, and  from  time  to  time.  Hepatic  stimulants  for 
habitual  use  are  found  in  ipecacuanha,  euonymin,  iridin 
taraxacum,  baptisin,  and  other  vegetable  products  ;  while' 
the  sulphate  and  phosphate  of  soda  are  also  adapted  for 
regular  use  (phosphate  of  soda  is  also  a  uric  acid  solvent). 
Some  prefer  the  chloride  of  ammonia.  Salicylate  of  soda 
is  a  potent  cholagogue. 

13—2 


i96  VA SO-RENAL  CHANGE. 

The  vegetable  hepatic  stimulants  seem  to  suit  best  the 
man  of  thin  flank — the  neurotic,  or  Arab  type ;  and  this 
is  still  more  true  of  women.  The  florid  gouty  woman  can 
take  the  uric  acid  solvents  ;  but  not  so  her  neurotic  sister. 
The  two  do  not  have  trouble  in  the  same  way,  and  require 
different  remedial  measures.  In  both  types,  however,  the 
regulation  of  the  dietary  is  indispensable. 

The  Dietary. — The  great  source  of  uric  acid  seems  to  be 
the  flesh  of  the  larger  animals.  Upon  this  matter  there  is 
agreement  among  modern  authorities  on  gout.  Whether 
there  is  any  failure  in  the  primary  digestion  of  proteids  of 
this  derivation  in  the  alimentary  canal ;  or  the  defect  is 
strictly  limited  to  the  liver,  is  a  matter  not  yet  determined  ; 
nor  likely  to  be  for  some  time  to  come.  But  the  empirical 
fact  remains  that  a  dietary  which  excludes  this  class  of 
food  suits  best  the  person  who  is  the  subject  of  lithiasis  in 
any  of  its  numerous  forms.  The  neurotic  girl  instinctively 
avoids  animal  food — by  that  same  law  of  self-preservation 
which  guides  animals  to  avoid  poisonous  plants  and  seeds. 
White  meats,  as  chicken  and  rabbit,  are  less  harmful  than 
brown  meats  (the  cook  sometimes  classes  pork  and  veal 
among  the  white  meats,  which  is  a  mistake).  Game  and 
other  birds,  of  course,  are  meats.  Nor  does  the  flesh  of 
birds  differ  essentially  from  the  flesh  of  beasts.  The  duck 
and  goose  are  brown  meats  (but  goose's  liver  is  a  capital 
form  of  food,  albeit  the  English  race  has  such  prejudices 
against  pate  de  foie  gras)  ;  so  is  the  turkey.  Fish  is  an 
excellent  form  of  food,  although  it,  too,  is  flesh.  The 
white  fishes  are  the  most  suitable  for  persons  of  the  uric 
acid  formation.  Shell-fish  of  all  kinds  are  good  ;  and  a 
lobster  salad  is  a  typical  dish  for  the  gouty  man — who  is 
perfectly  confident  about  his  digestive  capacities.  The 
oyster,  with  its  huge  liver,  is  good  food. 


PRACTICAL  CONSIDERATIONS.  197 

Of  all  forms  of  albumen,  caseine  seems  to  possess  the 
least  tendency  to  go  wrong  in  its  metabolism  in  the  body. 
A  milk  dietary  often  gives  good  results  in  cases  of  Bright's 
Disease.  The  Semitic  Arab  drinks  milk  and  eats  fruit ; 
and  so  did  the  Hebrew  of  old,  who  travelled  to  '  a  good 
land  flowing  with  milk  and  honey.'  Flocks  and  herds  did 
the  patriarchs  of  old  possess  in  large  quantity ;  but  they 
did  not  eat  of  the  flesh  of  them  :  as  is  shown  by  the  story 
of  the  aged  Isaac  and  the  savoury  meat.  Corn  and  oil 
and  wine,  too,  they  delighted  in  ;  and  cakes  of  fine  flour 
and  oil  were  in  common  use.  But  the  flesh-pots  of  Egypt 
were  not  good  ;  though  apparently  some  murmurers  looked 
back  to  them  with  regret. 

Many  modern  neurotic  Arabs  of  the  uric  acid  formation 
are  instinctively  adopting  the  food-customs  of  the  Arab 
and  the  Israelite  ;  and  with  advantage.  Pork  and  beef,  the 
delight  of  the  Norseman,  are  injurious  to  them ;  and  'the 
plain  roast  and  boiled,'  which  the  English  housewife  holds 
to  be  so  wholesome,  is  just  so  much  poison  to  them. 
The  plain  joint  of  Old  England  has  played  its  part  in 
history  ;  and  the  Merry  Monarch  knighted  the  sirloin. 
And  in  the  days  of  old  beef  was  measured  out  by  the  yard. 
The  Norse  rovers  found  the  pig  a  very  convenient  animal 
for  their  purposes.  He  had  a  good  constitution,  and  a  sea 
voyage  did  not  disagree  with  him.  His  food  require- 
ments were  simple  ;  and  his  victuals  could  easily  be 
stored  beside  him  in  a  corner  of  the  long  war-keel.  Other 
and  later  voyagers  also  realized  his  advantages  at  sea. 
Indeed,  the  Anglo-Saxon  has  had  an  attachment  to  the 
omnivorous  brute  since  the  dawn  of  history.  Up  to 
a  very  recent  period  fresh  pork  was  the  only  unsalted 
meat  of  a  country  mansion  in  the  winter  months.     The 


198  VASO-RENAL  CHANGE. 

boiled  round  of  salt-beef  and  the  roast  loin  of  pork  were 
with  many  a  country  squire  his  staple  dishes  for  a 
considerable  portion  of  the  year.  Such  food-customs 
continued  for  generations,  and  were  accompanied  by 
much  physical  exertion  in  the  open  air.  Field  sports, 
games,  work  on  the  land  for  long  hours  each  day,  enabled 
our  old-world  ancestors  to  endure  their  dietary,  and  to 
convert  this  nitrogenized  waste  into  urea  with  considerable 
success.  But  times  have  changed.  '  Tempora  miitantur, 
et  nos  mutantur  in  Mis !' 

With  town-dwellers  this  is  most  certainly  true.  And 
the  inhabitants  of  the  town  are  now  the  larger  half  of  the 
population.  The  tendency  of  town  life  to  transform  the 
Norse  type  into  the  neurotic  type  has  been  pointed  out 
before.  The  man  in  town  sets  off  to  an  office,  usually  an 
ill-ventilated  room,  at  the  hour  when  his  grandfather  set 
out  on  a  hunting  excursion.  Active  exertion  in  a  bracing 
atmosphere  enabled  a  liver  to  deal  very  differently  with 
waste  matters  and  luxus  consumption,  to  what  it  can  on 
the  clerk's  high  stool,  or  the  merchant's  office  chair  in 
an  impure  atmosphere.  But  this  matter  is  too  often 
overlooked  in  the  calculation.  '  None  of  my  people  ever 
had  the  gout,'  a  town-dweller  will  exclaim  with  surprise 
to  a  medical  man  who  makes  the  diagnosis  of  gout  in  his 
case:  Certainly  they  lived  under  widely  different  circum- 
stances. Their  livers  had  the  help  of  plenty  of  exercise 
and  oxygen  to  carry  on  the  urea  formation.  Their  modern 
descendant's  liver  is  handicapped  by  the  rebreathed  air  of 
rooms  and  offices  at  a  temperature  of  700  Fahr. ;  and 
so  reverts  to  the  uric  acid  formation  of  the  old  Saurian  in 
a  tropical  swamp.  Is  there  anything  to  be  surprised  at  in 
that  ?     On  all  sides  one  hears  the  remark  :   '  How  common 


PRACTICAL  CONSIDERATIONS.  199 

gout  is  nowadays  !'  How  could  it  very  well  be  other- 
wise ;  when  meat-eating  is  the  practice  of  the  wealthy, 
and  the  aspiration  of  the  poor  ?  Meat  is  the  one  means 
of  acquiring  health  and  strength  in  the  eyes  of  many. 
Town  life  tending  to  the  impairment  of  the  digestive 
organs ;  the  increasing  consumption  of  meat  by  everyone 
that  can  afford  it :  are  producing  results  which  could  easily 
be  calculated  a  priori. 

In  connection  with  this  matter  of  the  consumption  of 
animal  food  by  town  populations  as  compared  to  the 
rustic  population,  especially  of  past  generations — we  must 
have  regard  to  the  other  fact  of  the  defective  oxidation  of 
town  life.  In  the  country,  much  of  the  work,  and  the 
chief  of  the  amusements  are  in  the  open  air  ;  while  in 
towns  it  is  very  different.  Work  is  carried  on  by  an  urban 
population  in  close  confined  rooms,  with  even'-  crack  and 
crevice  closed  against  the  income  of  air — in  their  dwellings 
the  same  is  the  case ;  while  their  amusements  are  indoor, 
with  even  a  still  more  vitiated  atmosphere.  Their  meat- 
eating  customs  encumber  the  liver ;  while  defective 
oxygenation  hampers  it  still  further.  If  the  kidneys 
become  diseased,  secondary  to  liver  reversion,  then  it  is 
amongst  town  populations  we  may  look  for  the  prevalence 
of  vaso-renal  change. 

A  large  proportion  of  our  population  are  discovering  for 
themselves  that  vegetarianism  and  teetotalism  suit  them 
best.  They  are  reverting  in  more  ways  than  one.  They 
are  turning  back  to  the  Celto-Iberians  as  regards  their 
digestive  organs ;  and  blindly  and  unreasoningly,  but 
wisely,  they  also  are  reverting  as  to  their  food-customs. 
Farinaceous  matters,  fruits  and  milk  are  their  dietary. 
The  milk-pudding  is  supplanting  the  roast  beef  of  Saxon 


20D  VASO-RENAL  CHANGE. 

England.  The  water-caraffe  is  taking  the  place  of  the 
black-jack  filled  with  foaming  ale.  Spiers  and  Pond 
have  established  a  vegetarian  restaurant.  In  the  United 
States  the  bottle  of  aerated  water  with  a  basin  of  ice  has 
taken  the  place  of  the  wine  bottle,  till  the  American 
travellers  in  Europe  have  been  studied  by  the  innkeeper 
to  see  how  far  Boniface  can  compensate  himself  for  their 
neglect  of  his  wine  list.  The  Australians  drink  tea,  it  is 
reported,  to  an  extent  that  is  injurious  to  them.  Tea  and 
coffee  are  the  stimulant  beverages  for  the  modern  neurotic  ; 
who  recoils  from  the  jugs  of  ale  Queen  Bess's  maids  of 
honour  quaffed  at  their  breakfast  when  they  made  eyes  at 
Sir  Francis  Drake,  and  Sir  Walter  Raleigh  won  the  heart 
of  Elizabeth  Throgmorton.  For  most  of  the  wearers  of 
'  the  blue  riband,'  any  such  badge  is  perfectly  superfluous. 
The  slight  physique,  the  comparatively  large  head,  and 
thin  flank  mark  them  out  quite  sufficiently.  The  burly 
boor  of  old,  fond  of  his  corner  at  the  tavern,  is  giving  way 
to  the  slim  clerk  off  to  a  temperance  meeting,  or  the 
Young  Men's  Christian  Association. 

It  is  no  use  ignoring  facts.  The  physician  of  to-day 
has  to  look  beyond  the  walls  of  his  study,  or  the  wards  of 
his  hospital ;  and  see  how  events  are  moving  outside — if 
he  wants  to  know  what  is  going  on  around  him.  His  father 
talked  of  '  the  change  of  type  in  disease  '  as  his  lancet 
rusted  in  its  case.  Feeding  up  took  the  place  of  venesec- 
tion ;  and  now  we  are  beginning  to  find  out  that  feeding 
up  is  not  a  panacea  for  all  evils.  There  are  some  livers 
which  forbid  that  plan  for  resuscitating  the  race,  and 
endowing  the  town-bred  child  of  to-day  with  the  constitu- 
tion of  a  Viking  of  old — -well-meant  efforts  doubtless  ;  and 
if  a  certain  place  is  paved  with  good  intentions,  graveyards 


PRACTICAL  CONSIDERATIONS.  201 

contain  many  a  mite  who  has  succumbed  to  well-meant 
attempts  to  feed  it  up. 

The  modern  physician  has  been  looking  too  much 
inwards,  towards  his  test-tube,  and  into  his  microscope ; 
and  too  little  outwards,  in  this  matter.  If  he  would  read 
his  history,  and  then  take  a  turn  through  Madame  Tus- 
saud's,  or  the  picture-galleries  of  Hampton  Court  Palace ; 
he  would  find  himself  all  the  better  able  to  grapple  with 
the  cases  which  come  before  him  in  his  practice  and 
walk  in  life.  His  grasp  needs  widening.  Let  him  put 
what  he  sees  through  his  microscope  into  contact  with 
what  he  observes  in  Shoreditch,  and  its  congeners  ;  and 
with  what  he  sees  at  the  market-places  of  country  towns 
on  market-days.  This  would  give  him  some  solution  of 
the  fact  that  vaso-renal  change  is  on  the  increase  at  the 
present  time ;  and  that  reversion  to  the  uric  acid  forma- 
tion is  part  and  parcel  of  a  greater  reversion.  There  is 
a  reversion  of  a  type,  and  that  involves  a  reversion  of 
food-customs — under  penalty  of  disease  and  premature 
death.  No  wonder  the  spring  has  a  tendency  nowadays 
to  run  down  too  quickly ! 

If,  too,  it  is  the  fact — as  it  certainly  appears  to  be  the 
fact — that  the  heightening  of  the  nervous  system  goes 
hand-in-hand  with  waning  power  in  the  digestive  organs ; 
or,  in  other  words,  that  the  evolution  of  the  nervous 
system  of  the  epiblast  involves  the  involution  of  the  hypo- 
blastic  tissues  ;  some  other  matters  than  the  dietary  ought 
to  be  looked  to  a  little  more.  Is  it  quite  fair  on  the  part 
of  parents  to  foster  the  tendency  of  their  children  to  move 
in  the  neurotic  direction ;  as  is  done  on  all  sides  ?  The 
country  child  grows  thews  and  sinews,  and  develops  into 
a  stalwart  adult.     The  town  child  goes  to  theatres  and 


202  VASO-RENAL  CHANGE. 

parties — all  stimulating  its  nervous  system  and  dwarfing 
its  physique  :  it  cannot  eat  its  cake  and  have  it.  It  is 
a  man,  or  woman  of  the  world  at  twelve ;  whether  it  is 
lounging  in  a  carriage  in  Belgravia,  or  engaged  in  the 
interchange  of  chaff  in  Whitechapel.  The  town  child  has 
everything  in  action  to  favour  precocity;  in  open  defiance 
of  the  old  adage,  '  Soon  ripe ;  soon  rotten.'  It  is  not  an 
elegant  expression  —  it  is  very  plain,  unvarnished  old 
Saxon  :  but  it  is  true. 

In  connection  with  the  matter  of  early  precocity — or, 
in  other  words,  abbreviated  infancy — the  town  child  mani- 
fests a  reversion  to  an  earlier  or  lowlier  ethnic  form. 
Fiske,  in  his  '  Cosmic  Philosophy,'  states,  in  speaking  of 
infancy  :  '  In  the  human  race  it  is  much  longer  than  in 
any  other  race  of  mammals ;  and  it  is  much  longer  in  the 
civilized  man  than  in  the  savage.'  He  adds  a  foot-note : 
'  In  this  connection  it  is  interesting  to  observe  that  the 
phenomena  of  infancy  seem  to  be  decidedly  more  marked 
in  the  anthropoid  apes  than  in  other  non-human  primates. 
At  the  age  of  one  month  the  ourang-outang  begins  to 
learn  to  walk,  holding  on  to  convenient  objects  of  support, 
like  a  human  infant.  Up  to  this  time  it  lies  on  its  back, 
tossing  about,  examining  its  hands  and  feet.  A  monkey 
at  the  same  age  has  reached  maturity,  so  far  as  locomo- 
tion and  prehension  are  concerned.'  But  the  ultimate 
development  of  the  ourang-outang  extends  far  beyond 
that  of  the  lowlier  monkey. 

There  is  one  other  matter  still  to  be  considered  in 
connection  with  the  reaction  of  the  epiblast  upon  the 
hypoblast ;  and  the  reversion  of  the  congenitally  insufficient 
liver  to  the  uric  acid  formation  :  specially  noteworthy  in 
'  this  madlv  striving  age.'     There  is  the  haste  to  get  rich. 


PRACTICAL  CONSIDERATIONS.  203 

It  has  been  pointed  out  before  that  many  of  the  migrainous 
dyspeptic  ladies  told  of  the  long  strivings  of  their  fathers. 
The  effect  of  mental  strain  upon  the  viscera  has  been 
considered.  The  fathers  derange  their  digestive  organs 
by  their  brain-labour.  They  beget  children  with  incapable 
livers.  To  hard-working  men  this  is  a  most  serious 
matter.  If  their  efforts  to  accumulate  a  competence 
exercise  an  injurious  influence  upon  the  physique  of  their 
progeny — and  the  facts  certainly  point  in  that  direction — 
many  men  may  pause,  and  slacken  their  haste  to  be  rich. 
That  the  vaso-renal  change  is  associated  with  fortune- 
making  seems  beyond  all  question.*     ■ 

Vaso-renal  change  existed  in  the  past :  and  probably 
such  of  the  old  sea-rovers  as  did  not  get  killed  in  battle 
died  of  some  outcome  of  it.  Man}-  a  Teuton  baron  in  his 
hall  died  some  years  before  his  time  from  his  appreciation 
of  the  labours  of  his  cook.  But,  all  the  same,  it  is  widely 
on  the  increase  amidst  modern  town-populations.  Rever- 
sion to  the  primitive  uric  acid  formation  is  part  of  a  larger 
reversion.  Change  of  type  is  carrying  with  it  changes  in 
food-customs — both  as  to  meat  and  drink.  The  stalwart, 
fair-haired  Norse  folk  are  passing  away,  and  the  Celto- 
Iberians  are  getting  their  own  again.  And  among  the 
many  other  matters  involved  in  this  reversal  is  the  patho- 
logical matter  of  vaso-renal  change  ;  while  the  inadequacy 
of  the  term  '  Bright's  Disease,'  with  our  present  acquaint- 
ance with  the  long  and  widespread  pathological  process 
is  clearly  apparent.  If  Richard  Bright  were  alive  at  the 
present  time,  he  would  be  the  very  last  man  to  wish  the 
term  to  be  retained. 

*  This  view  is  borne  out  by  the  frequent  occurrence  of  diabetes  and 
Bright's  Disease  among  Jews. 


L'EXVOI. 

In  the  preface  to  this  work  the  writer  announced  his 
intention  to  do  his  best  to  grapple  with  the  widespread 
chronic  pathological  process  to  which  he  applies  the  term 
'  vaso-renal  change  ;'  hoping  that  some  one  may  ultimately 
hit  off  a  happier  term.  He  has  done  his  best :  whatever 
amount  of  success  he  may,  or  may  not  have  attained. 

He  feels  that  such  a  work  is  scarcely  fitly  performed  by 
an  outsider  and  adventurer :  and  that  it  should  have  been 
executed  by  some  one  engaged  in  medical  teaching ;  and 
deputed  by  the  Royal  College  of  Physicians  to  watch  and 
note  the  advances  made  in  this  department  of  medical 
science  :  and  to  report  these  to  them  from  time  to  time  in 
the  form  of  lectures  delivered  before  them,  and  issued  to 
the  world  bearing  their  imprimatur.  But  as  this  has  not 
been  done,  nor  seems  within  measurable  distance  of  being 
done  :  the  advance  of  medical  knowledge  could  not  tarry 
till  the  venerable  corporation  in  Pall  Mall  wakened  up  : 
and  so  the  work  had  to  be  essayed  by  some  one  who 
would  adventure  it.  This  inactivity  in  the  College  is, 
however,  quite  consistent  with  its  history.  Its  magnates 
have  never  given  much  encouragement  to  the  advance  of 
medical  science  ;   but  have  rather  preferred 

'  To  live  and  lie  reclined 
On  the  hills  like  gods  together,  careless  of  mankind  ' 


UENVOI.  205 

General  Gordon  held  that  the  English  colonies  were 
first  made  by  adventurers  ;  and,  when  worth  taking  over, 
adopted  by  the  Government.  So  it  is  in  medicine.  When 
some  one  has  investigated  a  subject,  and  it  has  been 
accepted  by  the  profession,  it  finds  its  way  into  the  nomen- 
clature of  the  College  ;  the  examining  bodies  accept  it ; 
and  then  the  new  recruit  quietly  takes  its  place  alongside 
the  veterans  of  the  text-books — and  becomes  a  formal  part 
of  the  principles  and  practice  of  medicine  of  the  future. 
Whether  such  will  be  the  fate  of  the  present  venture  time 
will  tell. 

The  ideas  propounded  in  these  pages  have  in  part, 
more  or  less,  passed  through  the  minds  of  others.  As  to 
the  bulk  of  the  clinical  data,  they  have  been  gathered  and 
collected  by  various  and  numerous  observers  :  and  all  the 
writer  can  claim  is  to,  more  or  less  imperfectly,  give  order 
to  chaos ;  and  arrange  many  maladies,  now  standing  in 
our  text-books  as  separate  entities,  in  their  true  place  as 
parts  of  a  great  pathological  whole.  Possibly  he  may 
claim  something  for  seeing  disease  in  wider  relationships 
than  have  hitherto  been  accorded  to  it.  The  work  of 
Darwin  has  enabled  him  to  see  in  the  uric  acid  formation 
a  reversion  to  the  lower  and  earlier  urinary  products  of 
the  bird  and  reptile.  Evolution  involves  involution  :  and 
in  the  return  of  town-populations  to  an  earlier  and  lowlier 
ethnic  form  we  see  involution,  or  dissolution.  Within 
this  major  involution,  or  reversion,  we  can  recognise  a 
minor  reversion  in  the  liver — which  involves  a  long  train 
of  morbid  sequences  ;  albeit  it  may  turn  out  to  be  really  a 
long-sustained  self-preservative,  depurative  action  to  rid 
the  system  of  products  which  are  injurious.  There  is  the 
microcosm  within  the   macrocosm  ;    and   the  vaso-renal 


206  VA SO-RENAL  CHANGE. 

change,  hight  'Chronic  Bright's  Disease,'  may  be  Nature's 
means  of  weeding  out  degenerating  beings ;  whose  de- 
generation is  due  to  the  action  and  exigencies  of  town 
life. 

The  inquiry,  too,  brings  us  face  to  face  with  a  matter 
which  is  beginning  to  exercise  the  minds  of  medical  men 
who  observe  and  think — viz.,  the  relations  of  mental  toil 
to  visceral  derangements.  The  impression  is  rapidly 
forming  itself  in  many  minds  that  long-sustained  mental 
toil,  or  trouble,  or  vexation  has  an  injurious  effect  upon 
the  glandular  apparatus  of  organic  life.  The  effect  pro- 
duced upon  the  liver  especially,  ex  motu  animi,  is  being 
more  widely  recognised  than  hitherto ;  unless  we  go  back 
to  the  ancients.  Hepatic  reversion  to  the  uric  acid 
formation  injures  the  kidneys  ;  while  the  blood,  laden 
with  waste  matters,  sets  up  many  morbid  changes  else- 
where than  in  the  kidneys. 

But  of  the  increase  of  Bright's  Disease  amidst  us,  and 
especially  among  town-dwellers,  there  can  be  no  doubt. 
Town-dwellers  lead  a  mentally  more  active  life  than 
country  folks.  The  man  who  has  made  a  fortune  no 
longer  retires  to  the  country ;  but  seeks  in  a  town  the 
advantages,  and  conveniences  of  civic  civilization.  The 
demands  of  the  growing  organism  upon  the  nutritive 
powers  are  deranged  by  modern  education.  The  epiblast 
makes  demands  upon  the  mesoblast  at  the  expense  of  the 
hypoblast.  The  hard-working  father  begets  children  with 
insufficient  livers  which  revert  to  the  uric  acid  formation ; 
with  the  consequence  of  interstitial  nephritis.  The  re- 
turns of  the  insurance  offices  of  the  United  States  tell  of 
a  distinct  increase  in  the  amount  of  Bright's  Disease 
amidst  that  enterprising  and  industrious  people.     There 


VEX  VOL 


207 


is  no  such  thing  as  unalloyed  good  in  this  imperfect  world  ; 
and  vaso-renal  change  may  be  the  Nemesis  of  ambition 
and  of  fortune-making. 

That  various  parts  of  what  is  expounded  here  as  to  the 
vaso-renal  change  have  passed  through  the  minds  of  others, 
is  seen  by  what  now  follows. 

Dr.  Blackall's  work  on  '  The  Nature  and  Cure  of 
Dropsies  '  was  referred  to  in  the  introductory  chapter 
(p.  2),  and  is  a  very  remarkable  work.  Dr.  Quain  drew 
my  attention  to  it  ;  saying  how  narrowly  the  old  doctor 
had  missed  the  vaso-renal  change  in  its  entirety.  He 
observed  the  dropsy,  the  albuminuria,  the  occurrence  of 
inflammations  of  the  serous  surfaces,  and  effusion  into 
their  sacs.  He  speculated  as  to  the  association  of  dropsy 
and  albuminuria  with  renal  changes  ;  '  but  whether  this  is 
merely  accidental,  and  what  relation  it  bears  to  the  dis- 
charge of  serum,  must  be  left  for  future  observation.'  In 
discussing  the  causes  of  '  coagulable  urine,'  he  goes  on: 
'  But  the  most  important  and  most  fatal  of  all  agents  in 
producing  this  complaint  still  remains  to  be  mentioned — 
an  unsoundness  of  the  digestive  organs,  which  impairs  the 
nourishment  of  the  body,  vitiates  the  blood,  and  gives 
vigour  and  operation  to  every  other  cause.'  He  con- 
tinues in  the  next  sentence  :  '  The  free  use  of  spirituous 
liquors  greatly  contributes  to  such  an  incurable  taint,  and, 
independently  of  that  fact,  has  been  thought  by  many 
physicians  capable  of  exciting  a  true  dropsy.'  Then,  in 
a  discourse  upon  'Angina  Pectoris,'  with  which  the  work 
concludes — a  very  suggestive  association — he  notes  the 
fact  of  palpitation  occurring  with  it  ;  and  says  :  '  Palpita- 
tions are  often  rather  a  diminished  than  an  increased 
action  of  the  heart,  the  ineffectual  and  feeble  efforts  of  a 


208  VASO-RENAL  CHANGE. 

distressed  organ.'  He  is  troubled  by  the  fact  that  angina 
is  found  with  varying  states  of  the  heart — '  in  one  instance 
emaciated,  soft,  and  rotten ;  in  another  large,  very  hard, 
and  strong ;  in  a  third  the  left  ventricle  was  remarkably 
strong  and  thick.'  As  to  its  association  with  ossification 
of  the  coronary  arteries,  and  disease  of  the  walls  of  the 
aorta,  this  had  been  recognised  long  anterior  to  his  time. 
Morgagni  had  observed  the  cor  magnum  potius,  et  durum 
valde  ac  robustum. 

It  is  interesting  to  see  how  our  modern  acquaintance 
with  the  relations  of  syphilis  to  arterial  degeneration  had 
been  foreseen  darkly  by  Lancisi  and  Morgagni  ;  while 
Scarpa  held  that  '  aneurysm  of  the  aorta  is  much  more 
frequently  produced  by  a  slow,  morbid  degeneration  of  it 
than  by  violent  exertions  of  the  whole  body,  blows,  or  an 
increased  impulse  of  the  heart.' 

Dr.  Blackall  was  a  thoughtful  observer,  and  in  con- 
nection with  the  vaso-renal  change  the  following  sen- 
tences are  of  high  interest.  In  considering  angina,  he 
writes  :  '  Whatever  differences  of  opinion  may  still  sub- 
sist as  to  the  constitutional  cause  which  brings  on  changes 
of  structure  in  the  arterial  system  generally,  and  the  par- 
ticular varieties  of  these  changes,  it  is,  I  believe,  unde- 
deniable  that  gouty  and  rheumatic  habits  are  most 
subject  to  the  angina  pectoris  ;  but  whether  it  is  that 
ossification  near  the  heart  occurs  more  frequently  in  such 
habits,  or  that  a  slighter  degree  of  them  produces  a  great 
impression,  may  admit  of  doubt.  This  disorder  makes  a 
slow  progress  with  indolent,  rich,  gouty  persons  ;  but  I 
have  seen  it  most  rapidly  destructive  in  a  spare  rheumatic 
habit,  subject  not  indeed  to  the  acute  form  of  rheu- 
matism,  but    to    nightly   pains   without    swelling.'      Dr. 


L'ENVOI.  209 

Blackall  in  this  clearly  recognises  the  two  types — the 
Norse  and  the  neurotic.  He  only  needed  the  aid  of  the 
microscope  to  have,  anticipated  the  knowledge  of  a  later 
•day.  It  was  no  fault  of  his,  but  his  misfortune  ;  that  this 
was  denied  him.     What  he  could  see,  he  did  see. 

The  same  division  of  individuals  has  suggested  itself  to 
another  good  observer,  Sir  Charles  Scudamore  ;  who  had 
a  very  true  eye  for  gout.  He  describes  a  class  of  gouty 
persons  presenting  more  or  fewer  of  the  following  phe- 
nomena, rather  than  articular  gout :  Headache,  eructa- 
tions which  are  sour  and  attended  with  a  sense  of  heat ; 
a  craving  appetite  which  does  not  become  comfortably 
satisfied ;  oppression  after  a  meal,  with  a  painful  sense  of 
distension,  and  soreness  of  the  whole  epigastric  region. 
Perhaps  a  slight  meal  causes  a  sense  of  fulness  and  dis- 
tressing oppression  ;  and  the  patient  feels  inflated,  or,  in 
his  own  words,  blown  up.  The  abdominal  muscles  are 
irritable,  and  convey  the  feeling  of  great  rigidity  on  exam- 
ination. To  these  may  be  added  a  furred  tongue,  with  a 
viscid  saliva,  especially  on  rising ;  its  taste  is  often  re- 
markably saltish.  There  is  much  thirst.  It  is  in  these 
persons  that  the  nervous  system  preponderates.  This 
picture  is  pretty  completely  descriptive  of  the  neurotic  of 
the  uric  acid  formation.  Others,  before  the  writer,  have 
noted  that  the  uric  acid  formation  runs  on  different  main 
lines,  according  to  the  diathesis  and  temperament  of  the 
individual ;  and  it  only  required  some  close  and  continued 
-observation  to  bring  out  the  different  points  in  each. 
And  the  division  into  the  '  Norse  '  and  '  Arab  or  Neurotic  ' 
for  persons  undergoing  the  vaso-renal  change,  has  been 
accepted  by  a  large  number  of  good  observers. 

The  effects  of  taxation  of  the  brain  as  '  the  organ  of 

14 


2io  VASO-RENAL  CHANGE. 

mind'  upon  the  glandular  apparatus  of  the  digestive 
organs,  and  the  withering  influence  it  exercises  there- 
upon, have  been  recognised  by  many ;  and  especially  Dr. 
Charles  Creighton  in  his  interesting  and  suggestive  work, 
'  Unconscious  Memory  in  Disease.' 

The  late  Dr.  Thomas  Laycock,  the  learned  Professor  of 
the  Practice  of  Physic  in  the  University  of  Edinburgh,  in 
discussing  the  metastases  of  gout  and  rheumatism,  held 
they  were  linked  by  a  common  origin  of  the  affected 
tissues.  For  he  wrote  :  '  Turning  to  the  facts  of  embryo- 
logical  development  or  formation  of  these  structures,  facts 
at  first  sight  are  contradictory ;  for  while  the  serous 
membranes,  neurilemma,  bone,  muscle,  and  motor  struc- 
tures in  general  are  developed  from  the  serous  layer  of  the 
embryo,  and  thus  a  community  of  origin  and  nutrition  is 
manifest  as  to  them ;  the  heart  and  large  vessels  are 
derived  from  another  primary  tissue.'  Professor  Allen 
Thompson  had  not  cleared  up  embryological  develop- 
ment when  Professor  Laycock  wrote  the  above  sentence  ; 
but  the  idea  of  disease  affecting  tissues  on  lines  mapped 
out  by  the  foetal  layers  was  clearly  present  to  his  mind. 

Mr.  Bland  Sutton,  in  his  recent  and  interesting  work, 
'  An  Introduction  to  General  Pathology,'  in  speaking  of 
neoplasms  and  their  classifications,  says :  '  The  most 
scientific  basis  on  which  to  found  a  classification  of  neo- 
plasms is  undoubtedly  an  embryological  one,  leaving  the 
histological  details  to  determine  the  varieties.  In  this 
way  they  are  divided  into  three  great  classes — those 
arising  from  tissues  mesoblastic  in  origin  ;  those  contain- 
ing tissues  formed  from  the  epiblast  and  hypoblast ;  and 
those  composed  of  tissues  derived  from  the  three  embry- 
onic layers.'     And    further,   he   writes :    '  The   mode   of 


L EN VOL  211 

classification  is  further  sanctioned  by  the  law  known  as  the 
specific  nature  of  tissues.  For  example,  the  cells  of  the 
epiblast  never  produce  bones,  neither  do  the  cells  of  the 
mesoblast  give  rise  to  epithelium;  and  this  specific  cha- 
racter of  the  tissues  arising  from  the  three  embryonic 
layers  is  maintained  throughout  the  whole  of  life.  Careful 
researches  confirm  this  law.' 

Then  as  to  the  heredity  and  antecedents  of  disease, 
my  old  friend  Clifford  Allbutt,  F.R.S.,  of  Leeds,  has 
broached  the  subject  in  an  interesting  manner  on  several 
occasions.  On  my  submitting  to  him  an  outline  of  the 
present  essay,  he  writes  me  : 

'  The  views  contained  in  your  letter  interest  me  very 
much.  When  you  ask  me  if  I  agree  with  them,  I  reply 
that  I  agree  with  you  cordially  in  your  main  contention  ; 
and  admire  your  method  as  a  most  fruitful  one.  Any 
difference  we  may  find  between  ourselves  in  detail  is 
of  secondary  importance.  If  I  understand  you  aright  you 
are  possessed  by  the  conviction  which  I  began  to  preach 
in  the  Medico -Chirurgical  Review,  in  1863,  that  the 
only  true  nosology  must  be  founded  on  the  genetic 
relations  of  maladies  and  affections  ;  and  the  true  method 
of  investigating  disease  is  to  trace  its  ramifications  and 
variations  through  as  many  generations  as  possible.  At 
the  bedside  I  have  tried  for  many  years  past  to  ascertain 
whether  the  woe  of  bringing  special  constitutional  defects 
into  society  could  be  laid  to  the  account  of  certain  races 
of  men  ;  and  whether  our  so-called  tubercular,  strumous, 
gouty  habits,  and  so  forth,  are  indications  of  qualities 
which  belong  to  elements  of  racial  admixture.  The 
enormous  difficulty  of  making  even  plausible  approxima- 
tive schedules  of  such  kind  has  hitherto  deterred  me  from 

14 — 2 


2i2  V A  SO-RENAL  CHAXGE. 

formulating  even  sketches  of  such  schedules  in  any  public 
form.  Moreover,  great  as  is  the  inherent  difficulty  of  the 
inquiry,  its  difficulty  is  enormously  exaggerated  by  the 
reasonable  and  unreasonable  prejudices  of  men. 

'  That  men  should  shrink  from  exposing  the  defects  and 
weaknesses  of  their  family  characters  is  natural  and 
reasonable ;  and  such  reticence  must  be  respected ;  on 
the  other  hand,  we  have  to  complain  that  we  are  misled 
ignorantly,  stupidly,  and  even  wilfully  when  searching 
into  family  histories  on  a  legitimate  mission.  During  the 
time  of  my  association  wTith  the  Collective  Investigation 
Committee,  I  urged  very  strongly  that  complete  stories  of 
family  tendencies  should  be  sought  for,  as  such  stories  are 
only  known  to  the  older  and  more  trusted  practitioners. 
But  you  make  the  more  ambitious  attempt  to  penetrate 
beyond  the  human  family,  and  to  investigate  the  phe- 
nomena of  comparative  biology  ;  as  I  urged  in  my  address 
to  the  Medical  Section  at  Worcester  in  1882  ;  and  beyond 
that  to  interrogate  the  phenomena  of  primary  tissue- 
development,  of  which  subject  I  lie  in  too  much  igno- 
rance. If  I  may  quote  from  my  address,  I  will  remind 
you  of  these  words  (Rep.  Brit.  Med.  Journal,  August  12, 
1882)  :  "  We  have  to  work  out  the  genetic  affinities  of 
diseases  themselves — their  origin,  parentage,  and  alliances, 
as  well  as  their  issues.  We  must  seek  out  and  define  the 
laws  or  powers  inherent  in  matter  by  which  diseases 
appear,  develop,  vary,  vanish,  or  prevail ;  and  this  not  in 
the  limited  field  of  man  alone,  but  far  beyond  it.  The 
medical  Darwin  has  yet  to  arise  who  will  map  out  the 
evolution  of  disease.  .  .  .  We  can  have  no  complete 
therapeutics  until  the  science  of  comparative  nosology  is 
in  great  measure  constructed."     A  little  later  in  the  dis- 


VEX  VOL  213 

course    I    refer  to   "the   long  series    of  affections  which 
belong    to    the    order    of  lithiasis    with    its    families    and 
genera."     But  I  shall  weary  you  :   and  I  will  at  once  pass 
on  to  a  point  of  view  in  which  I  may  not  find  you  my 
opponent,  but  which  may  not   coincide  with  that  which 
you  have  now  undertaken  to  display.     I  am  well  known 
to  be  a  fanatic  for  the  nervous  system.     If  I  am  then  made 
somewhat  blind  to  the  power  of  other  systems  more  or 
less  equivalent,  at  any  rate  I  deny  that  I  can  thus  be  led 
to   overrate    the   paramount    importance   of  the    nervous 
system.      The   nervous   system  seems    to   me  to    be  the 
register  and  organ  of  hereditary  influences  ;  and  I  believe 
that  in  ultima  ratione  nervous  changes  lie  at  the  back  of 
the  arthritico-renal    series  and    form   their  nexus.      For 
instance,    I     do     not     think    the    relationship    between 
lithaemia  and  chronic  cardio-renal  disease  is  direct,  but 
indirect ;   that  is,  I   believe  they  descend  from  common 
ancestry,  if  I  may  so  speak — but  do  not  generate  either 
the  other  in  the  way  of  direct  reproduction.     That  the 
cardio-renal  changes  are  "the  consequences  of  gout,"  as 
we  see  it  crudely  said,  I  do  not  believe.     Cases  meet  us 
every    day  in  which    persons    suffered    from    pronounced 
lithiasis    for    many   decades,  and    died    with    their    limbs 
crippled,  having  never  shown  any  marked  signs  of  cardio- 
renal  change  of  the  kind  we  have  now  in  view.     Athero- 
matous changes  with  anginiform  symptoms  are,  indeed, 
more  common  in  these  than  the  simpler  hypertrophy  with 
reno-arterial    fibrosis.     On   the   other   hand,  we   see   this 
latter  disease  in  persons  who  belong  to  gouty  families,  but 
who  have  shown  either  no  common  signs  of  lithiasis,  or 
in    whom    these    have    quite    a    secondary   position.     No 
paper    of    mine,    indeed,    has    received    a    more   general 


214  VASO-RENAL  CHANGE. 

adhesion,  or  been  more  regularly  quoted  by  later  writers, 
than  that  of  1876,  in  which  I  pointed  out  that  "prolonged 
nervous  strain  was  a  potent  cause  of  'granular  kidney.'  " 
The  common  factor  at  the  back  of  these  diseases  is  some 
bias  of  the  nervous  system  ;  and  '  gout  and  granular 
kidney '  are  rather  second  cousins  than  parent  and 
child. 

'  The  relation  of  migraine  to  these  maladies,  again,  is  a 
very  interesting  question,  and  may  prove  to  be  a  copula, 
or  clue  to  many  morbid  kinships. 

'  Finally,  I  will  not  delay  you  longer  to  ask  you  to 
watch  closely  the  relations  of  phthisis  to  these  diseases- 
That  phthisis  and  the  more  primary  and  malignant  forms 
of  "  granular  kidney  "  run  together,  I  am  pretty  sure  ;  and 
so  does  phthisis  with  acute  rheumatism,  the  more  atonic 
forms  of  gout  and  glycosuria — the  last  taking  us  directly 
to  a  definite  nervous  centre. 

'  I  think,  in  a  word,  your  forthcoming  book  is  likely 
even  to  exceed  your  former  ones  in  placing  vividly  before 
the  practitioner  of  medicine  the  wider  aspect  of  this  sub- 
ject ;  and  in  investing  his  work  with  more  interest  by  your 
skill  in  grouping  and  colouring  the  details  which  labourers 
in  other  fields  have  accumulated  in  their  more  isolated 
way.' 

This  expression  is  highly  gratifying  to  me  ;  and  the 
part  played  by  the  nervous  system  has  not  by  any  means 
been  overlooked  in  these  pages  ;  and  as  our  knowledge 
waxes,  we  may  come  to  find  it  all  that  Dr.  Allbutt  claims 
for  it.  I  venture  to  think  that  most  readers  will  agree 
with  him  that  such  grouping  of  diseases  makes  the  sub- 
ject all  the  more  interesting  ;  both  as  to  the  whole,  and  as 
to  individual  factors. 


L'ENVOI.  215 

Dr.  Lauder  Brunton,  F.R.S.,  has  approached  the 
matter  of  reversion  to  the  uric  acid  formation,  from  some 
experiments  performed  by  himself  and  Dr.  Cash,  in  a 
paper  in  the  '  St.  Bartholomew's  Hospital  Reports  '  for  the 
current  year  ;  and  in  writing  to  me  he  concludes :  '  Our 
idea  was  that  we  should  thus  be  able  to  find  out  the  action 
of  drugs  on  organisms  which  chiefly  excrete  urea,  and  on 
those  which  excrete  uric  acid.  Our  hypothesis  was  that 
we  should  find  the  action  of  drugs  on  the  uric-acid- 
excreting  organisms  in  all  probability  similar  to  those  on 
gouty  patients,  especially  during  the  paroxysm  ;  but  we 
did  not  think  ourselves  at  liberty  to  publish  our  hypo- 
thesis until  we  had  some  experimental  data.  As  you 
have,  however,  formulated  very  clearly  and  precisely  the 
same  hypothesis,  it  is  no  longer  necessary  for  us  to  wait ; 
and  we  have  consequently  mentioned  our  plan  of  research 
in  our  paper  in  the  "  St.  Bartholomew's  Hospital  Report  " 
for  this  year.  I  think  that  in  all  probability  we  might  have 
waited  for  years  before  we  had  accumulated  as  much 
evidence  as  we  wished  before  publishing  our  ideas  ;  and  it 
is  very  doubtful  if  we  should  ever  have  formulated  the 
reversion  idea  so  crisply  as  you  have  done.' 

These  matters  and  expressions  of  opinion  tell  that 
'  the  thing  is  in  the  air.'  In  conversations  with  many  of 
our  leading  teachers  and  authors,  the  writer  has  found 
others  thinking  along  the  same  lines  as  himself;  and 
recognising  the  widening  relationships  of  what  has  been 
hitherto  called  '  Bright's  Disease.'  That  the  first  depar- 
ture is,  as  Hayles  Walshe  insisted, '  a  change  in  the  blood,' 
by  which  the  vascular  system  and  the  kidneys  alike,  in 
time,  become  affected,  is  clearly  recognised ;  and  equally 
so  that  at  the  present  and  in  the  recent  past  the  matter 


2i6  VASO-RENAL  CHANGE. 

has  been  regarded  too  exclusively  from  the  standpoint  of 
the  kidney  and  its  secretion. 

Of  course,  the  present  essay  does  not  presume  to  claim 
to  be  exhaustive  of  the  subject ;  but  it  is  believed  to  pretty 
fairly  represent  the  knowledge  of  to-day.  To  many  readers 
it  will  be  little  more  than  their  own  ideas  writ  at  some 
length.  To  others  it  will  doubtless  contain  much  that  is 
unfamiliar  to  them  ;  but,  possibly,  not  on  that  account 
untrustworthy,  or  valueless.  The  writer  certainly  has  felt 
himself  the  better  practitioner  as  these  views  have  formed 
themselves  in  his  mind  ;  and  has  learned  to  recognise 
the  fact,  that  much  of  the  disease  of  middle  age  and 
advanced  life  are  truly  depurative  efforts  on  the  part  of 
the  system  :  and  he  can  only  trust  that  his  readers  will 
have  the  same  experience.  Busy  men  in  practice  require 
books  which  will  bring  to  them  the  information  they  feel 
they  should  like  to  possess;  but  have  not  the  time  to 
gather  and  work  out  for  themselves.  The  writer  there- 
fore hopes  this  little  work  will  meet  a  want  ; 

'And  where  the  vanguard  halts  to-day, 
The  rear  will  camp  to-morrow.' 


INDEX 


PAGE 

Affections  of  Skint        -           -           -           -           --         -  71 

Albuminuria             -                                         -             -             -             -  122 

Aneurysm                 -             -             -             -    '         -             -  97 

Angina  Pectoris      -                                       -             -             -             -  90 

Apoplexy    --------  99 

Arab  Type               -             -                          -             -             -             -  58 

Arterio-capillary  Fibrosis  -                          -             -            -             -  .     6 

Articular  Gout         -             -             -             -             -             -             -  48 

Atheroma    -             -                          -----  94 

Biliousness-             -             -             -             -             -             -             -  69 

Bronchitis  Chronic              -             -             -             -             -  52 

Change  of  Type      -  •  -  -  -  -  39?  59 

Congestion  ot  Diseased  Kidney    -----  173 

Connective  Tissue,  Growth  of                                                             -  29 

„                 „        in  Kidney         -                          -             -             -  33 

Coronary  Arteries,  Changes  in       -             -             -             -             -  1 57 

Death,  Slow            -             -                                       -             -             -  174 

„       Sudden       -             -             -             -             -             -             -  173 

Descent,  The          .__..'_                          -             -  165 

Depurative  Action  of  High  Tension           -                                       -  25 

„   ■        „       Dr.  Mott  on    -  26 

Development  of  Localised  Areas  -                          -             -             -  14 

Diagnosis  of  Gout  -  -  -  -  -  -  "85 


2j8  INDEX. 

PAGE 

Dietary        -  -  -  -  -  -  -  -196 

Digestive  Troubles  -  -  -  -  -  63 

Dropsy        -  -  -  -  -  -  -  -173 

Eczema       ---___  --54 

Effects  of  Town  Life  -  -  -  -  -  -       40 

Embryonic  Tissues  -  -  -  -  -  29 

Emphysema  -  -  -  -'  -  -       54 

Epistaxis     --------     102 

Fatty  Degeneration  of  the  Heart  -----     149 
Fibrillar,  Fatty        -  -  -  -  -  -  -     158 

Gout  in  England     -  -  -  -  -  -  16 

Glycosuria  --------     127 

Heart,  Fatty  Degeneration  of        -  -  -  -  -     149 

,,      Neuroses  of  -  -  -  -  -  -       78 

„      Secondary  Valvulitis  in       -  -  -  -  55 

Insurance  Office  View  of  Life        -  -  -  -  -     176 

Joint  Gout  --------       48 

Kidney,  Changes  in  -  102 

„        Congestion  of  Diseased    -  -  -  -  -     172 

„        Normal      -------     IO-j 

Lead  ----/---.-     147 

Liver  Reversion      -  -  -       12 


Mental  Phenomena 


74 


Microscopic  Appearances,  History  of        -  -  "-         3 

Migraine     -----  ..72 

Miliary  Aneurysm  -------     100 

Nails  in  Gout  -  -  -  -  -  -  -       86 

Neuroses,  Cardiac  -  -  78 

Neurotic  Type        -  -  -  -  -  -  "59 


INDEX.  219 

PAGE 

Palpitation  -  -  -  -  -  -  -90 

Poor  Man's  Gout    -  -  -  -  -  -  -11 

Psoriasis      -  -  -  -  -  -  -  "55 

Relations  of  Liver  and  Stomach    -  -  -  -     192 

Rheumatism  -  -  -  -  -  -  -       51 

Semeia  of  Gout       -             -             -  -  -  -  "85 

Skin  Affections        -             -            -  -  -  -  ~       71 

Stage,  Advanced     -------     148 

,,      First              -             -             -  -  -  -  "42 

,,      Middle         -            -            -  -  -  -  -90 

Stomach  and  Liver,  Relations  of  -  -  -  -  -     183 

Surgical  Aspect  of  Vaso-Renal  Change  -  180 

Teeth,  Gouty  -             -             -             -             -             -             "§5 

Traube's  Views  -------         5 

Treatment  -  -             -             -             -             -             -             -     194 

Tube  Casts  -             -             -             -             -             -     116 

Type,  Arab  -             -                          -             -             -                    58 

,,      Norse  -             -             -             -             -             -                    52 

Urate  of  Soda,  Deposits  of  -             -             -             "5° 

Uric  Acid  Formation,  The             -  -             -         9 

,,         Relations  to  Acute  Disease  .-•'-_     ig2 

Urine  in  Vaso-Renal  Change  -             -             -             -     118 

Valvulitis,  Secondary  -  -  -  -  -  -55 

Vascular  Changes  -  -  -  -  -'-  -42 

„        System,  Changes  in  144 

Vaso-Motor  Disturbance  .    -  -  -  -  17 

Venous  Fulness      -------     170 


FINIS. 


Bailliere,  Tindall,  &>  Cox,  20,  King  William  Street,  Strand. 


Stacks  b\)  the  sumz  Author. 


THE  HEART  AND  ITS  DISEASES:  with  their 
Treatment  ;  including  the  Gouty  Heart.  Second  Edition. 
Pp.  516.     1 5s. 

CHRONIC  BRONCHITIS  :  its  Forms  and  their  Treat- 
ment.    Pp.  1 60.     4s.  6d. 

INDIGESTION,   BILIOUSNESS,  AND   GOUT. 
Part  I.— Indigestion  and  Biliousness. 
Second  Edition.     Pp.  320.     73.  6d. 

Part  II.— Gout  in  its  Protean  Aspects. 
Pp.  300.     7s.  6d. 

THE      DISEASES      OF     SEDENTARY     AND 

ADVANCED   LIFE.     Pp.296.     7s.  6d. 

THE  PRACTITIONER'S  HANDBOOK  OF  TREAT- 
MENT, OR  THE  PRINCIPLES  OF  THERAPEUTICS. 
Third  Ecition.     Pp.  666.     18s. 

MANUAL   OF   DIETETICS.     Pp.  263.     gs.  6d. 

FOOD  FOR  THE  INVALID,  THE  CONVA- 
LESCENT, THE  DYSPEPTIC,  AND  THE  GOUTY.  Second 
Edition.     Pp.  167.     3s.  61 


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